Nursing & Healthcare News

Fewer Opioid Prescriptions, More Fentanyl Deaths

Are prescribing restrictions now aiming at the wrong target?

Someone has their hands surrounding an orange prescription bottle on a black countertop.

As the CDC prepares new opioid prescribing guidelines, the growing prevalence of fentanyl-related deaths raises questions about the effectiveness of continuing to crack down on prescription opioids.

CDC Guideline Revision

In February, the CDC released a draft of its updated opioid prescribing guideline. When finalized, the revised guideline will replace the controversial 2016 guidelines, which sought to stem the opioid crisis by reducing overprescribing and reigning in the escalation of dosages.

While the CDC intended the 2016 guidelines as recommendations rather than hard-and-fast rules, many areas have formalized those recommendations in law, regulation and organizational policy.

That has significantly reduced opioid prescriptions, but at a cost.

“The 2016 CDC guidelines resulted in major consequences for many who experience pain,” the American Society for Pain Management Nursing (ASPMN) declared in a public comment in April, noting that “the unyielding application of rigid opioid dosing limits” has hurt patients who need opioids “to enable function and an acceptable level of pain relief.”

Outdated Assumptions?

A recent study also questions one of the underlying assumptions behind the CDC guideline: the correlation between opioid prescriptions and opioid mortality.

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“The 2022 guideline … continues to cite the positive relationship between opioid prescribing rates and overdose deaths between 1999 and 2010,” remark the authors, “but makes no mention of the fact that those relationships have not existed for more than a decade.”

Based on 2010–2019 data from the same sources the CDC uses, the study’s authors concluded that the current relationship between opioid prescriptions, overdose deaths and treatment admissions is now “either non-existent or significantly negative/inverse,” nationally and in 48 states.

California Opioid Deaths Have Tripled

In California, opioid deaths continue to increase despite reductions in opioid prescribing. Between 2010 and 2016, California patients filled an average of 23.4 million opioid prescriptions each year. By 2021, that figure had fallen to 14.8 million, and the state’s opioid prescription rate (per 1,000 residents) had declined by more than 40 percent.

This steep decline in opioid prescriptions did not reduce opioid mortality. In fact, opioid overdose deaths in California more than tripled: from 2,039 in 2016 to 6,843 in 2021. Opioid overdose ED visits also doubled between 2016 and 2020.

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A Fentanyl Crisis

Over the past five years, the principal driver of opioid mortality has been the potent synthetic opioid fentanyl. Fentanyl is found in some prescription painkillers, but drug suppliers frequently use it to supplement or substitute for other narcotics, particularly heroin.

In 2016, only 239 California opioid overdose deaths were fentanyl-related. By 2021, annual fentanyl-related deaths were up to 5,722 and still climbing. Fentanyl is now involved in more than 80 percent of all opioid deaths in the U.S. The CDC acknowledges that the fentanyl involved in those deaths is “more likely to be illicitly manufactured than pharmaceutical.”

A 2021 study suggests the troubling possibility that policies targeting opioid overprescription may be contributing to this trend by leading more people to use opioids “in the absence of close medical supervision,” and perhaps to “supplement … prescription opioid regimens with heroin and/or fentanyl.”

Seeking Balance

ASPMN wants the revised CDC guideline to emphasize the importance of “a balanced and comprehensive approach [to pain relief], including opioids and non-opioid pharmacological and non-pharmacological therapies based on an individualized assessment of the patient.”

However, legislators and regulators who have enacted opioid prescribing limits based on the 2016 guidelines may be reluctant to walk back those limits, afraid of reopening the pre-2010 floodgates. Finding a happy medium between those extremes may be a long, painful process.


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