Suggested Paths to Fixing the Opioid Crisis

Abstract

The opioid crisis and its morbid and mortal consequences have captured the public spotlight, and rightly so. In response, public health professionals have pursued a variety of approaches in analyzing data to highlight aspects of the crisis that may help inform a solution. Two current articles in JAMA Network Open, " The Burden of Opioid-Related Mortality in the United States " 1 by Gomes et al and " Patterns of Immediate-Release and Extended-Release Opioid Analgesic Use in the Management of Chronic Pain, 2003-2014 " 2 by Hwang et al, add to the current discussion and reveal some potential for misdirection from the goal of reversing current trends in opioid use. Gomes et al 1 provide a report on poisoning deaths related to opioids over time from a Centers for Disease Control and Prevention database. They find that the rate of such deaths increased during the 15-year period (2001-2016) of observation. A more than 3-fold increase in opioid-related deaths among individuals aged 15 to 24 years and those aged 25 to 34 years is striking, as is the fact that in 2016, 1 in 10 deaths in the former and 1 in 5 deaths in the latter were related to opioids. It is tragically clear that opioids, and overdose in particular, have played an enormous role in deaths among younger and middle-aged adults. We should also note that many of these deaths involve more than opioids in isolation. Our own query of the Centers for Disease Control and Prevention WONDER Multiple Cause of Death database showed that among opioid-related deaths for 2016 (n = 43 491), alcohol, cocaine, or benzodiazepines were also present in 19 646 deaths (45%). 3 Such data help to illustrate our challenge. Opioid poisoning, with and without other substances, identifies a tragedy. The question is whether or how these analyses might point toward solutions. One seductive target for action is restraint of opioid prescriptions: their dose, duration, and formulation. 4 A case can be made that risk will be attenuated by attacking all 3 aspects of prescribing, and policy makers and regulators have taken up this solution with enthusiasm. However, such regulatory efforts have also inaugurated a tide of nonconsensual tapers in otherwise stable patients, for which evidence of benefit is lacking 5 and reports of harm are concerning. 6 What about avoiding certain higher-risk formulations? Data from Hwang et al 2 hint that the return on investment for prescribing extended-release/long-acting (ER/LA) formulations may be low.