DOCTORS DEFY FEDERAL OPIOID CRISIS SAFE PRESCRIBING RULES FOR HIGH-RISK POPULATION
The vulnerable population of disabled adults unsafely prescribed opioids by licensed medical professionals are 3% of the U.S. population and “account for 25% of opioid-related overdose deaths and hospitalizations”
by Clark Miller
Published March 28, 2025
Here’s the headline from an online medical news site –
That’s one way of putting it, but we’ll need to rewrite that once we see what the study actually found. We’ll get to that soon, below.
From the online news piece –
A new study led by researchers at the Harvard Pilgrim Health Care Institute found that a 2019 Medicare opioid safety policy showed initial reductions in opioid prescribing to high-risk populations. However, the policy’s effectiveness diminished over time. …
Medicare provides coverage for 9 million U.S. adults with disabilities under the age of 65. Despite representing only 3% of the U.S. population, these beneficiaries account for 25% of opioid-related overdose deaths and hospitalizations. On January 1, 2019, the Centers for Medicare & Medicaid Services (CMS) required all Medicare Part D plans to implement an opioid safety policy. This policy limits new opioid users to a 7-day supply and restricts prescriptions to no more than 90 morphine milligram equivalents daily. ..
Results suggest that the 2019 Medicare opioid safety policy reduced the length of initial opioid prescriptions and the frequency of high-dose prescriptions from multiple-prescribers among Medicare beneficiaries with disabilities. While the 7-day safety edit led to immediate and sustained reductions in initial opioid prescriptions exceeding 7 days, these reductions diminished by the end of the study period. The 90-MME limit resulted in an immediate reduction in concurrent multiple-prescriber high-dosage episodes; though this effect was reversed when COVID-19 flexibilities rolled back the 90-MME edit. These findings, the researchers say, show that the work to curtail the opioid crisis should remain ongoing, evolving, and evidence-based.
“While our analysis reveals immediate reductions in high-risk opioid prescribing, our analyses show that these reductions diminished over time, highlighting the need for further research to understand crucial downstream policy effects and subpopulations at risk,” added Dr. Wen. “Policymakers and insurers should consider additional clinical and culturally nuanced interventions that address medical and social risk factors of opioid misuse.”
[emphasis added]
That headline and associated reporting convey that the study found safe prescribing success due to compliance with opioid prescribing safety standards by America’s licensed medical professionals (LMPs), success that did decrease in effectiveness somewhat over time.
That sounds pretty good, an overall gain, progress in the opioid crisis that will have long-term effects of increasing protection of vulnerable Americans from risk of opioid dependence and associated health and mortality risks.
But it’s a lie.
Let’s take a deeper look.
From the JAMA research report –
Findings This interrupted time-series study found that in a cohort that was new to opioid use (476 859 patients), the 7-day safety edit was associated with a sustained reduction in the days’ supply of an initial opioid fill; however, reductions in 30-day total MME and likelihood of developing long-term opioid use diminished over time. In addition, in a cohort with long-term opioid use (3 295 299 patients), the 90-MME safety edit was associated with a reduction in concurrent multiple prescriber high-dosage episodes, but this improvement was reversed when COVID-19 policies rolled back the patient-prescriber consultation requirement. …
Results The new-to-opioids cohort included 476 859 person−index months (mean [SD] age, 55.7 [7.8] years; 281 536 [59.0%] women). The long-term opioid cohort included 3 295 299 person−index months (mean [SD] age, 56.3 years [6.6]; 1 887 547 [57.3%] men and 1 407 752 [42.7%] women). The 7-day safety edit was associated with immediate and sustained reductions in the likelihood of an initial opioid prescription filled for more than 7 days’ supply (start of the post-policy period: 46.7 % reduction; 99.5% CI, −48.3% to −45.2%; end of study period: 43.8% reduction; 99.5% CI, −45.7% to −41.9%). In contrast, moderate immediate reductions in the likelihood of development into long-term opioid use (13.8% reduction; 99.5% CI, −20.5% to −7.2%) diminished by the end of the study period (4.0% reduction; 99.5% CI, −10.4% to 2.4%). The 90-MME safety edit was associated with an immediate 36.1% reduction (99.5% CI, −42.8% to −29.4%) in the number of concurrent multiple-prescriber high-dosage episodes, which was reversed when the COVID-19 flexibility rolled back the 90-MME edit.
Conclusions and Relevance The findings of this interrupted time-series study of Medicare Advantage beneficiaries younger than 65 years with disabilities show that the 2019 Medicare opioid safety policy was associated with shorter initial duration of opioid prescriptions and fewer concurrent multiple prescriber high-dosage prescriptions of opioids. Given that downstream reductions appeared to be transient, further interventions are needed to address the clinical and social risk factors for opioid misuse among beneficiaries with disabilities.
[Emphasis added]
Okay …
With imposition of CDC prescribing guidelines, there was a lasting effect on frequency of opioid prescriptions for patients new to opioids that were written for no more than 7 days. That seems good … or meaningless, depending entirely on whether that prescription was renewed and the length of period opioids were prescribed after that, as well as the dose, represented by the morphine milligram equivalent (MME) value.
That’s because there is a well establshed relationship linking the risk of someone prescribed opioids becoming dependent on them to the amount (daily dose) and length of time they are dispensed those opioids by their LMP. That makes sense.
And that’s why the study included a measure of “likelihood of developing long-term opioid use”, the results of that measure glossed over (not reported) in the medical news report, and lied about in the research report in America’s top medical journal.
Let’s take a look. In the JAMA research report, results were spun this way:
In contrast, moderate immediate reductions in the likelihood of development into long-term opioid use (13.8% reduction; 99.5% CI, −20.5% to −7.2%) diminished by the end of the study period (4.0% reduction; 99.5% CI, −10.4% to 2.4%).
“CI” means confidence interval, and translated, this language (13.8% reduction; 99.5% CI, −20.5% to −7.2%) describing outcomes of statistical analysis means exactly this: that we can conclude with high (95%) confidence that the likelihood, or risk, of developing into long-term opiod use reduced as a result of the changes, and that it reduced by an amount within the range of 20.5% to 7.2% less likely. We cannot conclude with any confidence that likelihood decreasing by any specific value within that range, or by any value outside of that range. That was for changes right after the prescribing rules were put into place by the CDC. So far so good?
Later in the study, when measured again, the results were as follows: 4.0% reduction; 99.5% CI, −10.4% to 2.4%. Notice that the values defining the confidence interval include a negative number (-10.4%) and a positive number (2.4%), the latter representing an increase in likelihood of development of long-term opioid use. The only accurate interpretation of this result is that we can conclude with 95% confidence that the likelihood of development of long-term opioid use decreased or increased. That is, we cannot conclude a reduction in likelihood.
So, the conclusion provided in the JAMA article, that “reductions in 30-day total MME and likelihood of developing long-term opioid use diminished over time” is a lie by omission and distortion. The accurate conveyance is that after initial reduction in likelihood of developing long-term opioid use following CDC directives, in follow-up measurement no indication of reduction in that risk was statistically indicated.
That result is congruent with the other outcomes provided in the study including the reversal of moderate reductions in MME limits once restrictions were lifted, and the conclusion that “downstream reductions appeared to be transient”.
So, if we cut through the distortions and Expertspeak, what are we left with?
This.
That for a particularly vulnerable population – disabled adults under age 65, with highly disproportionate risk of opioid related hospitalizations and overdose deaths – as soon as America’s LMPs could ignore safe prescribing guidelines for opioids, they did, resulting in no lowering of opioid-related risk for that population.
That corrected headline needs to read:
Doctors Defy Safe Prescribing Guidelines for High-Risk Population, with No Reduction in Risk For Long-Term Opioid Use
And how was that outcome spun in media reports and in America’s top medical journal?
Like this:
“These findings, the researchers say, show that the work to curtail the opioid crisis should remain ongoing, evolving, and evidence-based.”
Right. Because prior to these findings, no one would have thought to suggest that “the work to curtail the opioid crisis should remain ongoing, evolving, and evidence-based”. Right? Could any construction of words in this context have been more meaningless? That of course, was exactly the point of that insipid suggestion – to pronounce something so mind-numbingly inane as to completely distract from the real import of the results.
And this:
that the lack of any reduction of risk to this vulnerable population due to their exposure to opioids by their doctors is “highlighting the need for further research to understand crucial downstream policy effects and subpopulations at risk,”
Further research! Of course. There can never be enough, especially when the real outcomes and how they are spun into lies are so damning that the desperate need is to pay no attention to what you see here, new research will confirm our expected results.
And this, from JAMA:
“Given that downstream reductions appeared to be transient, further interventions are needed to address the clinical and social risk factors for opioid misuse among beneficiaries with disabilities.” Translation: Given that LMPs failed to change prescribing practices to ensure lowered risk for this vulnerable population, interventions will be required to manage opioid misuse among the disabled patents doctors are unsafely overprescribing to.
As noted by the research lead author quoted in the online medical news report, “Policymakers and insurers should consider additional clinical and culturally nuanced interventions that address medical and social risk factors of opioid misuse.”
Those policymakers and insurers are almost certainly getting on that task right now, are all over it. And there is no nuance needed to address the type of reckless, knowing exposure of vulnerable patients to overprescribed opioids decades into a lethal epidemic generated largely by doctor prescriptions. It’s the job of medical licensing boards to take action up to removal of medical licenses when something like that happens.
That could work to reduce risk of harm by reckless and unsafe prescribing, except for the problem: that in the cronyism, entitlement system known as the “medical field” that doesn’t happen, is systemically protected against.
From licensing boards to medical schools, to the U.S. Supreme Court, LMPs are protected from consequences for the harms generated by reckless unsafe prescribing.
Those protections may help to explain additional features of America’s LMP opioid prescribing.
Like failing to change prescribing in response to pharmacy-generated messages warning of potentially dangerous opioid + benzodiazepine polypharmacy.
And an outlying practitioner having to admonish colleagues at a national meeting for unsafe prescribing practices in 2023.
2023, after decades of a worsening crisis and mounting deaths.
and this
and this
and this
and this
There’s more, of course, but we can wrap this up.
There’s the persistent, harm-predicting dispensing of epidemic-fueling addictive substances for the entirely non-medical condition of chronic pain.
And continuing harm-predicting dispensing of epidemic-fueling addictive, diverted, and abused substances for the entirely non-medical condition of compulsive substance use.
And persistent dispensing of harm-predicting substances without benefit for the entirely non-medical condition of depression.
From appearances and evidence, the problem behaviors are systemic and free from accountability, correction, or self-regulation informed by clinical and ethical competence, as if driven by impairment, as if characterological and immune to social protective forces.
