Does Restricting Opioids Lead to More Heroin Overdose Deaths?

Turns out Neonatal Abstinence Syndrome (NAS), a condition suffered by newborn babies of opioid-addicted mothers, isn't the only risk to children in the fight against opioid misuse and abuse.  A JAMA Pediatrics article published yesterday showed a more than 2-fold increase in hospitalizations among children due to opioid poisonings.  While the bulk of these hospitalizations were predictably among older adolescents, the fastest growing cohort of hospitalizations occurred among the youngest children (toddlers and pre-schoolers) who can't tell the difference between candy and OxyContin.  A follow-on piece in the Washington Post fairly equates this public health risk to the gun control debate. Lock up the guns, lock up the drugs - our kids are paying too high a price.  

In other news, this month's Health Affairs contains a really interesting article on the relationship between state laws and opioid / heroin overdose deaths (Health Affairs 35, No. 10 (2016); 1876-1883).  Here are the high level conclusions:

• States that pass laws pertaining to mandatory physician review of PDMP data and the strict licensing of pain clinics reduced opioid amounts prescribed by 8% and opioid overdose death rates by 12%.  
• The study also observed a large (though statistically insignificant) reduction in heroin overdose death rates.  This might be counter-intuitive to you because some believe cutting off the supply of opioids in a community creates risk of increased heroin use.  

The public policy conclusions here are important.  First, if passing these common-sense laws really does lead to decreases in opioid supply and overdose deaths, there isn't any good reason not to implement mandatory PDMP checks and strict pain clinic laws (unless you live in Missouri... in which case irrational concerns over privacy consistently inhibit adoption of sound public health policy). 

Second, the study found "no evidence to support the assertion that policies to curb opioid prescribing are leading to heroin overdoses."  This doesn't mean that heroin overdoses haven't been on the rise; in fact, they've been increasing in virtually every state in the country.  What the study authors are saying is that new opioid restrictions do not appear to be accelerating the rise in heroin overdose deaths.  

Opioid and heroin abuse is clearly a complicated public health problem.  But this data suggests we should avoid the policy trap of using the one (potential heroin overdose deaths) as an excuse to not do the other (restrict the opioid supply through mandatory PDMP checks and strict pain clinic licensing). If there is data out there to the contrary, I'd honestly love to see it.  I think it's important to litigate these studies to ensure we're moving in the right direction.
  

As the devil can cite scripture for his purpose, we all seem able to find anecdotes to support our policy views.  Stories can be powerful illustrators of truth, but let's make sure we use data to guide our public policy discussions. 

Michael 

On Twitter @PRIUM1

Oxycontin for Kids

The FDA has approved Oxycontin for children. 

Before I editorialize, a few important facts:

• Specifically, the approval is for children ages 11-16 that require daily, round-the-clock, long-term pain relief for which no other alternative exists. 
• FDA actually requested that Purdue study this; this isn’t Purdue trying to extend its patent through dubious means.
• The only other FDA-approved long acting analgesic available to kids who have, say, incurable cancer, is Duragesic (or fentanyl).
• I have an 11 year old.  

That last fact turns out to be pretty important.  My first reaction to this news was outrage.  I’ve never pulled punches with my criticism of the FDA and I was fired up to skewer them again for being utterly tone deaf to the greatest public health crisis of our time.  But I first saw this news while sitting at the breakfast table with my three kids, the oldest of whom is 11.  After finishing a few articles on the FDA move, reading emails from several of you who struck tones of anger and confusion in varying degrees, and processing my initial shock, I looked up at my kids and wondered…

I am incredibly blessed to have healthy kids.  But if my kid had incurable cancer and he was suffering from intractable pain, would I want him to have Oxycontin available to him?  Yep.  I sure would. 

On the other hand, I thought… What if he blew out an ACL playing soccer when he’s 15?  Would I want him to have Oxycontin for post-op recovery, even if he was in great pain?  No.  Absolutely not. 

If we trust that Oxycontin will be used only in those extenuating and heart breaking circumstances for which this approval is intended, then I could support that. 

But what if the message coming through armies of pharma reps employed by Purdue is that Oxycontin is now approved for “round the clock pain management, when no other alternative exists… even for teens suffering from post-op pain related to major sports-related surgeries…”?  Do we have proper controls in place to ensure that doesn’t happen?   One need only read this crushing article in Sports Illustrated to understand that we’re already overprescribing opioids to teens, particularly athletes.  How do we make sure this doesn’t make it worse? 

Pediatric oncologists are thrilled. 

Public health advocates are gravely concerned.    

I'm not comfortable with ambivalence, but in the case I have to admit: Both are right.  

Michael
On Twitter @PRIUM1