Opioids: Encouraging trends and new challenges

Kaiser Permanente Washington led in reducing opioids. We’re now seeing benefits, but there’s more work ahead, writes Dr. Michael Von Korff.

By Michael Von Korff, ScD, retired senior investigator, Kaiser Permanente Washington Health Research Institute

I see glimmers of hope in recent trends about opioids. U.S. opioid prescribing is declining and rates of fatal drug overdose are down for the first time since 1990.   

Opioid prescribing overall declined by about one-third from 2013 through 2018, reports the Food and Drug Administration Advisory Committee on Anesthetic and Analgesic Drug Products. Prescribing of high-dose opioid medications dropped by over 60 percent in the same time period.  

As a researcher studying chronic pain and opioid use, I’ve noticed these promising developments for some years. Starting around 2011, opioid prescribing trends shifted nationally from increasing to decreasing. I’m pleased to say that such reductions started at Kaiser Permanente Washington four years earlier, in 2007, because our medical staff took active steps to reduce overprescribing of opioid analgesics.

Leadership by Kaiser Permanente Washington  

Prescribing trends began changing nationally when a series of reports linked higher prescription opioid doses to increased risk of opioid overdose. The first of these reports included work published in 2010 by our group at Kaiser Permanente Washington Health Research Institute. The paper was accompanied by an editorial co-authored by A. Thomas McLellan, PhD, then Deputy Director of the White House Office of National Drug Control Policy, calling for changes in opioid prescribing.   

We recently reported that from 2007 to 2011, Kaiser Permanente Washington achieved a one-third reduction in combined fatal and nonfatal opioid overdose rates for patients using prescription opioids for chronic pain. Our population is not the only example. States that achieved large reductions in opioid prescribing seem to show reductions in opioid overdose deaths rates earlier than other parts of the United States.   
 
More good news came in July 2019: The Centers for Disease Control and Prevention reported that nationally, the number of drug overdose deaths declined 5 percent from 2017 to 2018. This was the first decrease in drug overdose deaths in almost three decades.

I’m especially encouraged because the numbers indicate that the work of health care teams paid off: The reduced number of opioid overdose deaths was entirely due to a drop in drug overdose fatalities involving prescription opioids. While it is too early to be sure, this may be the first sign that we are turning the corner on the epidemic of prescription opioid drug overdose and addiction.

Our next challenges

While the news about changes in prescription opioid prescribing and opioid overdose are positive, we have a rapidly emerging problem with fatal overdoses involving other opioid drugs: heroin and illicit synthetic fentanyl. Overdose deaths have been increasing rapidly since 2010 for heroin and since 2013 for fentanyl. The rise in overdose deaths from these drugs is probably because of their increased availability, low street price, and high potency. A real concern is that the widespread availability of prescription opioids led people to move from medically prescribed or illicitly used prescription opioids to heroin or fentanyl.

Still, the encouraging trends in prescription opioids show that we can find solutions to this new opioid crisis. But we need to act. The increasing numbers of people addicted to heroin and fentanyl plus several million people dependent on prescription opioids create an unprecedented need for addiction treatment services. Particularly important is medication-assisted treatment with drugs like buprenorphine.  

In addition, efforts to prevent or treat opioid misuse, abuse, and addiction must address chronic pain. This means finding ways for clinicians and care teams to assist patients with effective chronic pain management. It means prescribing and developing safer medicines and employing effective nondrug treatments—including complementary and integrative health therapies—that help people with chronic pain feel better and do more.

KPWHRI and Kaiser Permanente Washington led the country in reducing opioid overdose deaths through research and with evidence-based prescribing policies. With work underway at KPWHRI, we’re ready to continue leading in improving chronic pain care and preventing addiction.