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Will fewer opioid prescriptions help kick the crisis?

Doctors are less likely to write first-time opioid prescriptions to patients than they were nearly seven years ago, a recent study suggests. The data offers a rare glimmer of good news in the nation’s ongoing opioid crisis, but it’s unclear whether this shift in physician practice could help lower historic rates of fatal drug overdoses nationwide.

The study, published this week by Harvard University researchers in the New England Journal of Medicine, found that the monthly rate of first-time opioid prescriptions dropped by 54 percent nationwide between 2012 and 2017.

To better understand first-time prescription opioid use, researchers analyzed claims data from 63.8 million people who were age 15 or older, covered by Blue Cross Blue Shield insurance and had no known use of opioids in the last six months. Within that national sample, the rate fell from 1.63 percent in July 2012 to 0.75 percent in December 2017.

The number of health care providers who wrote first-time opioid prescriptions for their patients declined from more than 114,000 to nearly 80,500 during the same period. Overall, researchers found 89 million opioid prescriptions across five years, including 11 million new prescriptions.

Additionally, the study found that initial opioid prescriptions lasting longer than three days fell 57 percent since 2012 — a timeframe that lines up with national guidelines established three years ago. Prescriptions that exceeded seven days declined 67 percent, the study said. And health care providers who wrote any first-time prescriptions for opioids fell by nearly a third during the same five-year period.

Of all physicians, primary care doctors most frequently doled out first-time opioid prescriptions, and roughly 80 percent of those supplies lasted longer than three days. Dentists were least likely to write excessive first-time prescriptions for opioids, the study found.

Reacting to the crisis?

These new data points are a positive development, said Nicole Maestas, an economist and associate professor of health care policy at Harvard Medical School who served as this study’s lead author. In September, she led a study that found doctors had recorded no pain diagnosis for nearly 30 percent of patients who were nevertheless prescribed pain-killing opioids.

In 2017, 70,237 Americans fatally overdosed on drugs, a 9.6-percent increase over the previous year and the highest on record, according to the Centers for Disease Control and Prevention. A majority of those deaths — 47,600 — were linked to opioid use. That number rose by 5,000 opioid-related deaths since 2016, when 40 percent of which were tied to prescription — rather than illicit –drugs, according to the Department of Health and Human Services.

The CDC set guidelines for prescribing opioids for chronic pain in 2016 in an effort to stem the worsening opioid epidemic. (An estimated 11.5 million Americans had reported misusing prescription opioids that year.) These guidelines said opioids “are not a first-line or routine therapy for chronic pain,” and if they must be used, doctors typically should prescribe opioids at low doses for a duration of three days.

Yet these latest numbers suggest a shift in first-time prescribing practices that began even before the CDC released its guidelines, Maestas said, and the ripple effects could be promising.

Why it matters

Fewer excessive opioid prescriptions means “you’d have fewer leftover pills sitting in medicine cabinets around the country where they could be accessed for non-medical use,” Maestas said.

That resonates with what Daniel Alford says he sees in his practice as a general internist who treats patients with chronic pain.

“Gone are the days when someone comes in with a sprained ankle, and they get a 30-days supply of opioids,” said Alford, who directs the Clinical Addiction Research and Education Unit at Boston Medical Center and Boston University School of Medicine. and was unaffiliated with this study. “I don’t think that’s happening anymore. That’s good,” added Alford, who was unaffiliated with the study.

Alford said a combination of more judicious and fearful attitudes toward prescribing opioids has become more prevalent, both among physicians and patients. The new data showing a downturn in first-time opioid prescriptions was encouraging, he said, but still left key questions unanswered, like the right amount to prescribe to patients and whether this shift in prescription practice has resulted in better patient outcomes.

The study “debunks a popular narrative” about opioid prescription reform, said Andrew Kolodny, who co-directs opioid policy research at the Heller School for Social Policy and Management at Brandeis University and did not help produce the study.

For years, Kolodny said, critics claimed that “the CDC guidelines had a draconian impact” and led to a crackdown on prescriptions that left patients to suffer in pain.

But those guidelines alone had little impact on overall prescribing, he said. While opioid prescriptions are trending “in a more cautious direction,” Kolodny said, a large number of doctors made no changes and “continue to prescribe very aggressively.”

“If they’re prescribing aggressively, we’re still getting too many Americans addicted to opioids,” he said.

Prescription drug monitoring programs, which now track when people attempt to access an abundance of opioid medications from multiple doctors and pharmacies in all 50 states, have heightened attention to the public health crisis. Public awareness campaigns and media coverage have also shed light on the opioid epidemic.

Still, the policy levers used to monitor and curb extreme or potentially illegal behavior by doctors and patients — such as pill mills and doctor shopping — may not help identify average prescription practices that could still lead to detrimental health outcomes without intervention or treatment, possibly perpetuating more overdoses and deaths.

“We’re cautiously optimistic that providers are changing their behavior, but we really do have quite a ways to go,” Maestas said. “Until we see overdose mortality come down, we can’t say we’ve figured this out.”