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As it's been noted on the blog before, it's safe to say we are in the midst of a transition towards increasing restrictions on our ability to prescribe opioids to our patients, although the nature of these restrictions are really just emerging**.  All of this is, of course, in response to the horrifying epidemic of prescription opioid abuse - see this recent New York Times piece for a bone-chilling description of prescription opioid abuse in Appalachia.

Which is not to say that some of the recent high-profile scholarly publications on the risks of chronic opioid therapy make me very, very grumpy, at least how they are interpreted in the headlines and editorial page.  I've really appreciated Stewart Leavitt's ongoing, critical discussion of these publications (and the larger editorial/media conversation) at his Pain Treatment Topics blog, and I couldn't presume to do a better job analyzing the studies than Stew.  See, for instance, this analysis of two recent high-profile publications purportedly about the dangers of opioid therapy.  I read both the studies he mentions, as well, and thought to myself:  Gee, these studies seem to highlight how safe chronic opioid therapy is.  Read his analysis and the articles and decide for yourself, but I concluded the same thing he did:  while the risk of fatal overdose increases with increasing prescribed dose, the absolute risk of fatal overdose (in these studied populations) was exceedingly low. 

**Yes, I actually wrote those words last night.  Subsequently my inbox gets flooded with notifications that the FDA has announced its long-awaited REMS program for long-acting opioids...kind of.  Press-release here, which discusses, in broad-strokes, a multi-agency strategy (beyond REMS) to help stem the epidemic.  We are told the key elements of the strategy will be:

• expansion of state-based prescription drug monitoring programs
• recommending convenient and environmentally responsible ways to remove unused medications from homes
• supporting education for patients and health care providers
• reducing the number of “pill mills” and doctor-shopping through law enforcement

 All of this sounds swell of course, but the devil will be in the details, which are still forthcoming, and in part will be defined by manufacturers.  The plans, as far as prescribers are concerned, seem to be mostly about increased education, but nothing along the lines of requiring prescribers to complete and sign off on certain educational materials in order to prescribe certain drugs, etc.  Nods are given to the importance for balancing the needs of patients to receive pain relief and the public health catastrophe diversion and abuse of prescription opioids.  I still think, at the end of the day, that docs aren't detectives, we can't be, and with the exception of a tiny number of completely clueless prescribers and some criminals, targeting prescribers just isn't going to help.

I'd recommend reading Stew Leavitt's analysis for a more knowledgeable discussion of the announcement.

Photo from the FDA's press-release.

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The current New England Journal of Medicine has a perspectives piece by Timothy Quill and Diane Meier about the upcoming Supreme Court decision regarding the Oregon physician assisted suicide law (and whether the DEA or the state medical boards have the power to restrict physicians' use of controlled substances). Their take is that a decision in favor of the DEA will have a chilling affect on physicians' prescribing of controlled substances to dying patients, for fear of scrutiny for being involved in 'assisted suicide.' It is a chilling article and all I can say is that if the Supreme Court rules "against" the Oregon law, I hope Drs. Quill andMeier are wrong. A quote:

This type of DEA involvement in medical practice would adversely affect far more patients than those few who seek assistance with a hastened death in Oregon. If the government thus oversteps its legitimate role and expertise, allowing DEA agents, trained only to combat criminal substance abuse and diversion, to dictate to physicians what constitutes acceptable medical practice for seriously ill and dying persons, it will undermine palliative care and pain management for the much larger number of seriously ill patients in all states.

Free full-text is available.