Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

Abstract

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Figure 1.

The Opioid Paradox. Opioid prescriptions are declining while opioid overdose deaths are increasing. Data source: References ^,,

Figure 2.

The prescription opioid ecosystem. The pool of unused prescription opioids available for diversion, misuse and overdose is influenced by supply, demand, and return or disposal. Overprescription of opioids, while providing sufficient supply to treat pain, risks potential patient overuse or residual unused opioids, and underprescription risks undertreated acute and chronic pain. Reducing supply alone has not been successful at reducing opioid overdose rates. Reducing demand through better pain treatment, and enhancing disposal and return, are additional approaches to reducing the opioid pool and mitigating opioid misuse and overdose deaths.

Figure 3.

Analytic framework for prescribing opioids for acute pain and evidence linkages necessary to support the development of clinical practice guidelines for opioid prescribing. The framework begins with the patient population with acute pain (e.g., postoperative pain). The wide arrow indicates evidence evaluating the effects of an opioid prescribing strategy on a health or intermediate outcome. The dotted lines indicate linkages between different outcomes (e.g., association between a lesser amount of opioid used and risk of long-term use or quality of life), not between an intervention and an outcome (or, in the case of intermediate outcomes and long-term opioid use, between one intermediate and another intermediate outcome). Short- and long-term health outcomes, both beneficial and harmful, may be seen at the patient and community or population levels. Reproduced from Framing Opioid Prescribing Guidelines for Acute Pain: Developing the Evidence with permission of the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.

Figure 4

Surgery and opioids: Opioid safety and stewardship. Includes some information from Srivastava et al.