A question many chronic pain patients ask is do opioid legislations and regulations work? The answer isn’t cut and dry. One of the most pressing issues in medicine these days is also one of the most complicated. There is a fine balance between appropriate, responsible prescribing of opioids for patients who get tremendous benefits from them and reaching too often for the prescription pad before exhausting other options. For some patients, opioids offer pain relief when nothing else will; for others, opioids carry serious risks of dependence and even death. Recent legislation is attempting to find the balance between relief and regulation, with mixed success and divided opinion on both sides of the debate.
SO, Do Opioid Legislations And Regulations Work?
The two main issues that the majority of opioid-focused legislation attempts to address are over prescription and illegal use.
Legislation addressing this issue has been somewhat successful.
A new study by Johns Hopkins Bloomberg School of Public Health found that in Florida, two laws aimed at curbing over prescription and easy access to opioids reduced the number of prescriptions by 2.5%, with a dosage decrease of 5.6%. The first part of the law enacted a prescription drug monitoring program (PDMP) to track patient prescriptions and prevent doctor shopping. The second part tightened regulations on pain clinics with loose prescription monitoring and patient tracking (also known as “pill mills”).
Lainie Rutkow, JD, MPH, PhD, an associate professor in the department of health policy and management at the Bloomberg School of Public Health believes that these declines, though small, are significant and indicate that there is a concrete way to deal with the epidemic of over prescription, noting:
“These findings support the notion that there are policy solutions to the prescription drug epidemic.”
Another study from the University of Florida found another substantial benefit to Florida’s PDMP: a 25% drop in opioid overdoses in the two years following the law’s enactment. Bruce A. Goldberger, Ph.D., a professor and director of toxicology in the department of pathology, immunology and laboratory medicine, noted that previous studies have made it difficult to see specific effects of PDMP’s on specific drugs. This study’s results were much more clear:
“…we were able to tease out precise differences that showed us that Florida’s Prescription Drug Monitoring Program is having a sizable effect on the number of oxycodone deaths. This is a crucial first step in preventing overdose deaths and in establishing best practices for programs like these across the nation.”
According to the Drug Enforcement Agency, 37 states currently have prescription drug monitoring programs, but with the exception of Florida, there is limited understanding of whether or not they work to reduce over prescription or potential dependence.
The Centers for Disease Control cite PDMPs as “the most promising state-level interventions to improve painkiller prescribing, inform clinical practice, and protect patients at risk,” but they also acknowledge that research data as to their effectiveness is sparse. This could be due to uneven implementation and limited data sharing across states. Still, as in the Florida study, there is some indication that these laws are a step in the right direction.
One of the most difficult aspects of opioids to regulate is their illegal use. A poll from the Harvard School of Health found that over half of all people in the U.S. know someone who is illegally using prescription opioids.
Another study from the University at Buffalo found that more than 50% of chronic pain patients classified as “baby boomers” are misusing opioids. This group of patients in particular may have started with legal and appropriate use and gradually become dependent as they aged, or they may have started with an unnecessary prescription and become dependent.
Yu-Ping Chang, PhD, RN, associate professor and interim associate dean for research and scholarship in the UB School of Nursing, pointed out that this is especially problematic for older patients, saying:
“Older adults are at high risk for complications resulting from prescription opioid misuse. As the baby boomer generation ages and more patients are prescribed opioids, abuse is likely to become an even greater problem.”
Other attempts to manage illegal use may have been unsuccessful as well. OxyContin is one of the most widely abused prescription opioids, and although research has indicated that a recent reformulation of OxyContin makes it more difficult to abuse, the rate of illegal use and abuse is still alarmingly high. The new formula makes the pills more difficult to crush and snort, a common practice among opioid abusers, but not impossible.
Senior investigator in the Washington University of St. Louis study Theodore J. Cicero, PhD, a professor of neuropharmacology in psychiatry, noted that this change only worked to a point and also had a significant downside:
“We found that the abuse-deterrent formulation was useful as a first line of defense. OxyContin abuse in people seeking treatment declined, but that decline slowed after a while. And during that same time period, heroin use increased dramatically.”
Opioid dependence treatment options
In spite of the growing number of opioid-related deaths and reports of dependence, a recent study by Johns Hopkins found that the number of people seeking treatment for addiction has remained stagnant.
This may be due to the fact that opioid dependence is difficult to treat, but there are two promising approaches.
- Motivational interviewing (MI): The University at Buffalo study cited above found great success with motivational interviewing. This process listens to a patient’s problems empathetically and then helps them to see the gap between their desire to change and their behavior. This approach is non-confrontational and helps patients to make real, sustainable change in their behavior.
- Drug-assisted treatment: Office-based opioid treatment with buprenorphine (OBOT B) is another way that opioid-dependent people can get supportive help. This method of treatment uses another drug, buprenorphine, to ease the symptoms of withdrawal, and combines it with a nurse care model that treats opioid dependence like any other condition. This approach removes the stigma of opioid dependence and encourages people to get the treatment they need.
It is important to note that some patients experience profound relief using appropriately prescribed and monitored opioids for pain. In fact, 12 European countries are actually widening access to opioids to remove the stigma of seeking pain relief and to disassociate opioids from street drugs.
Professor Sheila Payne from the International Observatory on End of Life Care at Lancaster University noted that this expansion affects mainly patients receiving end-of-life care or those in chronic pain but believes that pain relief is an important right for patients, saying:
“There is a stigma of drugs on the streets which is why social attitudes are a big barrier in many of these countries. Opioids are treated as narcotics and very strictly controlled because there is a fear that opioids will cause addiction. But if they are used at the end of life or if people are in great pain, addiction is not a problem.”
The most important part of this debate is a conversation with your doctor about the potential benefits and risks of opioids. Talk to your doctor about your options.