Pain is everywhere. In the United States, nearly 66 million individuals experience acute pain from a surgery or procedure each year, and 100 million individuals suffer from chronic pain lasting weeks to years. The US has garnered the dubious honor of becoming one of the world’s largest consumers of prescription opioid analgesics, in part fueled by the changing perception of pain and pain management in the late twentieth century. However, there is no evidence to suggest that the US provides better pain management than our global counterparts, and morbidity and mortality attributable to opioids continue to rise.
In response, numerous state policies related to prescription pain management have emerged. Many of these policies are aimed at limiting the upstream source of opioids diverted into communities by reducing opioid prescribing, more so than combatting the “late effects” of opioid use such as addiction, dependence, and overdose. However, these upstream targets are also the source of pain management for many Americans with acute and chronic pain conditions, and the public perception of these policies is underexplored. Examining the cultural acceptability of these policies is key to predicting whether they will have their intended effect—to mitigate opioid-related harms by reducing the dispersion of opioids in the community.
Older adults may be especially affected by policies that restrict opioid access and impact pain management. Acute and chronic pain disproportionately affect older adults given their increased burden of health conditions, and older adults have historically high rates of being prescribed opioids. Although the population of older adults continues to grow, their views on opioid policies have remained largely unheard. The University of Michigan’s National Poll on Healthy Aging (NPHA) is a recurring, nationally representative poll of US older adults ages 50–80 years. In March 2018, the NPHA asked about older adults’ experiences with opioid prescribing and their perceptions of opioid-related policies that limit prescribing or encourage disposal of unused opioids.
Opioid Prescribing Limits: Does One Size Fit All?
Opioids lingering in medicine cabinets are a major contributor to the current public health crisis. By the end of 2018, 33 states had enacted policies to limit the number of pills that can be provided in a single opioid prescription. For prescriptions for acute pain, this limit usually ranges from 5 to 14 days. While this prescription length was meant to encompass the period of time in which acute pain would be expected to resolve, this may not correlate well with appropriate opioid use for any given condition. Moreover, limits may not account for the nuances of pain related to specific surgical procedures or other patient factors, such as tolerance, exposure, and preference.
This is reflected in the NPHA poll results: While 74 percent of respondents are in favor of prescribing limits, 26 percent did not support prescribing limits at all. Many patients require far less than the prescribing limit, which may create a “default” size that is greater than clinically advisable and results in excess pills left unused. Poll results found that one-third of older adults reported filling an opioid prescription within the past two years, and nearly half were prescribed more medication than ultimately needed. Conversely, patients may also have pain that exceeds the days’ supply limit, requiring the patient to obtain, fill, and pay for additional prescriptions. This can be particularly burdensome for those who have difficulty accessing transportation and limited financial resources.
Restrictive policies may inadvertently encourage patients to hold on to extra opioids: If patients are concerned that they will not be able to access pain medications when needed, they may be more likely to save unused medications instead of safely disposing of them. For example, the majority of poll respondents (86 percent) who saved leftover medication did so in anticipation of future use. Even among older adults who did not have leftover medication, 68 percent said they would have saved extra medication for future use if they did. Among older adults, misused opioids are most often obtained from their own leftover medications. Unsupervised use of opioid medications can result in unexpected interactions with other medications and accidental overdose. Finally, unused prescription opioids remain the leading source for diversion and nonmedical use to family and friends of all ages.
Improving Disposal: Access Versus Motivation
It is also possible that opioid disposal rates remain low due to limited access to the recommended methods of disposal, such as via authorized takeback locations. In fact, few respondents reported returning medication to designated takeback locations such as authorized pharmacies or police stations (13 percent). Distance from a takeback location may be challenging for individuals with transportation barriers, and others may not feel comfortable or safe entering a law enforcement agency with a controlled substance. Although community takeback events may provide a more socially acceptable alternative, these are only held periodically, and perhaps not at convenient times. Fewer respondents disposed of the unused medications at home by throwing them away or flushing them (9 percent). Home disposal methods, such as flushing or washing down the drain, may improve access to disposal but are controversial because they can result in measurable opioid levels in the environment.
Newer alternatives exist for safe home disposal such as over-the-counter products that deactivate medications, so that they can be safely thrown away in the trash. If a product like this were given for free, 39 percent of poll respondents said they would definitely use it and 38 percent of older adults said they might use it. Unfortunately, many existing home disposal products currently incur out-of-pocket costs for the patient. If the cost was $5–$10 for this product, most NPHA respondents reported that they would not purchase it (70 percent). Even if given a medication disposal pouch for free, 24 percent of older adults still would not use it. The most common reason cited to not use the product was that they would rather save their medication for future use (62 percent). These results underscore that simply offering access to a convenient method of disposal may not be adequate if patients are worried that they will not have access to prescription pain medications in the future.
Opioid Education: Can We Change The Culture Of Pain?
The poll findings suggest that there are cultural beliefs about pain management that must shift before current policy could be expected to reduce the burden of prescription opioids in the community. Although challenging and often slow, culture change is necessary among both prescribers and patients to effectively combat the opioid crisis. Education of both clinicians and patients is needed regarding risks, benefits, and alternative options for pain management that may even be more effective than opioids for chronic and acute pain conditions.
Many of these educational initiatives are already under way, although most are not yet mandated. For example, some states now require specialized training and continuing medical education to prescribe or dispense opioid analgesics. Education may include instruction on how to safely prescribe opioids and risks of prescribing these medications. Older adults indicated strong support (38 percent) or support (42 percent) for special training for health care professionals to prescribe or dispense opioids. These policies aim to increase education of patients through clinicians. Currently, only 60 percent of respondents report they were told by their prescriber or a pharmacist about side effects of opioids or when to reduce prescription pain medication use. Less than 50 percent of respondents report they were told about the risk of addiction or overdose, or what to do with leftover pills.
Effective policies must carefully balance dual public health challenges—opioid harms and pain—while remaining acceptable to both patients and prescribers. For some policies, such as prescription drug monitoring programs (PDMPs)—statewide databases that contain information for every controlled substance prescription dispensed—the views of older adults seem to align with opioid reduction efforts. Overall support for PDMPs was high with 95 percent of poll respondents either indicating strong support or support for required review of patient prescription records. Older adults may support PDMP checks because they can see the connection between provider awareness of their complete prescription history and reduced medication risks. Such instincts are consistent with emerging research that shows PDMPs to reduce opioid prescribing and prescription opioid-related death rates.
For other policies, such as disposal, views do not align with the evidence. When the NPHA proposed a new policy—required disposal of unused opioids—more than half of poll respondents (53 percent) were not in support. It is possible that older adults perceive disposal as a public health effort that places their own ability to treat pain in jeopardy by creating logistical and cost barriers. Recognizing respondent concerns—for example, regarding the over- and under-inclusiveness of prescription limits and the burdens of disposal programs—can inform opioid policies to make them acceptable to all stakeholders. In addition to integrating strong evidence alongside opioid-related policy, cultural expectations about pain must change before legislation can effectively create behavioral change and reduce opioid harms in the US.