Dramatic Reduction in Hydrocodone Prescriptions in an Urban Safety Net Health Care System: Has It Improved Patient Safety or Led to Increased Patient Suffering?

Pain management, chronic use of opioids for non-cancer pain, and opioid overdose have become nationwide public health challenges. According to a recent Institute of Medicine report, up to one-third of U.S. adults report chronic pain [1]. Following nationwide policy changes, updated practice guidelines, and the loosening of opioid prescribing restrictions in the 1990s, a dramatic increase was seen in the prescriptions of opioids for non-cancer chronic pain [2].In addition, over the last 20 years there has been a dramatic increase in opioid-related accidental overdoses and deaths, with 16,651 deaths attributed to prescription opioids in 2010 [3,4]. The majority of these deaths are attributable to long-acting opioids and methadone [5]. The increased mortality rate is due not simply to the overall increase in prescriptions but also to prescriber knowledge deficits, patient behaviors and co-morbidities, and payor and system policies [5,6]. In addition to the risk of accidental overdose and death, chronic use of opioids creates other risks to patient safety including abuse, addiction, transition to heroin use, diversion, and accidents [7]. Lastly, opioids can be associated with numerous adverse effects, such as constipation, sedation, hormonal imbalance, and hyperalgesia [8–10].At the same time, opioids are necessary to meet a critical need for adequate control of both acute and chronic pain in certain patient populations. Withholding and restricting necessary medical treatment may cause undue patient suffering [11]. In addition, prescriber bias and societal stigmas may result in unintended and problematic barriers to improved quality of life for certain groups [12].In response to increases in opioid-related morbidity and mortality, various recommendations have been made for safe opioid prescribing, including urine drug monitoring, state prescription monitoring databases, and treatment agreements …