The Opioid Dilemma: Saving Lives in the Long Run Can Take Lives in the Short Run

The following originally appeared on The Upshot (copyright 2019, The New York Times Company). 

The unavoidable tension in attacking the opioid crisis is which time frame you’re talking about.

In the short term, many policies that would limit opioid prescriptions for the purpose of saving lives would cause people to turn to heroin or fentanyl.

In fact, over a 5-to-10-year period, that would increase deaths, not decrease them, according to a simulation study published in the American Journal of Public Health. The study was conducted by three Stanford University researchers, Allison Pitt, Keith Humphreys and Margaret Brandeau.

“This doesn’t mean these policies should not be considered,” said Mr. Humphreys, a former senior policy adviser at the White House Office of National Drug Control Policy during the Obama administration. “Over longer periods, they will reduce deaths by reducing the number of people who initiate prescription opioids.”

A large proportion — 80 percent by one estimate — of heroin users in the United States previously used prescription opioids. In some cases, they were directly prescribed narcotic pain relievers, perhaps after a painful dental procedure or operation. In addition, drugs prescribed to one person can be diverted to others who don’t use them for medical purposes. So restricting opioid prescriptions would seem to make sense.

But it’s not so simple. That approach reduces access to drugs for people who legitimately need them for pain, as many readers, pointing to their own predicaments, have commented after Upshot articles on opioids.

Amie Goodin, a researcher with the University of Florida College of Pharmacy who wrote an editorial accompanying the opioid policy simulation study, said, “Current policies to limit opioid prescriptions leave some pain patients high and dry, resulting in a new wave of unintended consequences for patients with untreated chronic pain.”

“In addition to other approaches to addressing the opioid epidemic, there needs to be more nuanced prescribing rather than simply cutting people off opioids,” said Laura Burke, an emergency physician with Harvard Medical School and the Harvard T.H. Chan School of Public Health.

Prescriptions could be avoided for cases of mild-to-moderate pain — think of a sprained ankle or a tooth extraction. Opioids could largely be reserved for much more severe pain — accompanying major surgery and cancer, for example. “We should rely more on other therapies to help patients handle less severe pain,” she added.

The simulation study bears this out. Reducing opioids for short-term pain saves lives in the long run, even as it leaves some patients experiencing more pain. This is the fundamental trade-off opioids present, with which we have been battling for decades. As the pendulum swung further toward treating pain, opioid-related deaths ballooned. Now to stem the deaths, it is swinging back, challenging us to treat pain in other ways.


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