Peter Barglow1,2. 1. Former Professor of Psychiatry, Northwestern Medical School, Chicago, Illinois. 2. Former Professor in Residence and Chief of Addiction Medicine, UC Davis Medical School, Sacramento, California.
Abstract
BACKGROUND AND OBJECTIVES: Outcome intervention data from Medicare, veteran, prison, and United States' public populations can identify best practices to decrease opioid misuse. Prescription policies for treating pain in the United States and other countries are relevant to preventing overdose. METHODS: Three strategies are considered: (1) Demand Reduction counsels and educates patients and current or potential opioid users about risks and treatment options to reduce motivation to consume opioids. (2) Supply Reduction limits access and dosage of opioids and co-drugs such as benzodiazepines. It encourages use of safest prescribing practices for treating pain. (3) Harm Reduction reduces opioid deaths through medication-assisted treatment (MAT) combining opioid substitution therapy (OST), provision of opioid antagonists like Naltrexone, and behavioral health services. RESULTS: Demand Reduction is often inadequate to treat severe pain or in the presence of major psychopathology like opioid abuse disorder (OUD). Among veterans, lower opioid doses for pain treatment were associated with diminished death rates. Supply Reduction interventions have disadvantages. Banning drugs has poor long-term success with prison inmates, because abstinence is difficult to enforce after discharge. Limiting opioid supplies does not increase survival rates for Medicare patients. DISCUSSION AND CONCLUSIONS: Sharp opioid dose restriction in outpatient treatment increases heroin and fentanyl use, explaining why recent years' decrease in United States opioid prescriptions has not reduced national mortality rates. Although Harm Reduction is the safest, most effective single approach, combining three interventions while improving pain and addiction prescribing practices is optimal. SCIENTIFIC SIGNIFICANCE: Scientific research needs to inform choice of opioid overuse interventions. (Am J Addict 2018;XX:1-3).
BACKGROUND AND OBJECTIVES: Outcome intervention data from Medicare, veteran, prison, and United States' public populations can identify best practices to decrease opioid misuse. Prescription policies for treating pain in the United States and other countries are relevant to preventing overdose. METHODS: Three strategies are considered: (1) Demand Reduction counsels and educates patients and current or potential opioid users about risks and treatment options to reduce motivation to consume opioids. (2) Supply Reduction limits access and dosage of opioids and co-drugs such as benzodiazepines. It encourages use of safest prescribing practices for treating pain. (3) Harm Reduction reduces opioid deaths through medication-assisted treatment (MAT) combining opioid substitution therapy (OST), provision of opioid antagonists like Naltrexone, and behavioral health services. RESULTS: Demand Reduction is often inadequate to treat severe pain or in the presence of major psychopathology like opioid abuse disorder (OUD). Among veterans, lower opioid doses for pain treatment were associated with diminished death rates. Supply Reduction interventions have disadvantages. Banning drugs has poor long-term success with prison inmates, because abstinence is difficult to enforce after discharge. Limiting opioid supplies does not increase survival rates for Medicare patients. DISCUSSION AND CONCLUSIONS: Sharp opioid dose restriction in outpatient treatment increases heroin and fentanyl use, explaining why recent years' decrease in United States opioid prescriptions has not reduced national mortality rates. Although Harm Reduction is the safest, most effective single approach, combining three interventions while improving pain and addiction prescribing practices is optimal. SCIENTIFIC SIGNIFICANCE: Scientific research needs to inform choice of opioid overuse interventions. (Am J Addict 2018;XX:1-3).
Authors: Thomas Gaisl; Naser Musli; Patrick Baumgartner; Marc Meier; Silvana K Rampini; Eva Blozik; Edouard Battegay; Malcolm Kohler; Shekhar Saxena Journal: JMIR Res Protoc Date: 2020-12-08