Opioid Overprescription for Migraines

Opioid overprescription in the United States presents numerous questions for research. Demographic and economic factors related to those patients receiving a large number of opioids for relatively minor pain conditions is worth further investigation. Existing evidence shows that white race, for example, increases the probability of receiving opioids for migraine in the ER. It may be helpful to build on the research examining health disparities. It should be determined whether pain patients with certain characteristics are more likely to develop addiction and medication overuse headache, exhibit drug-seeking behaviors, or turn to heroin or other street drugs than others. Further relevant issues include access to and insurance coverage of both drug treatment and alternative pain management solutions in patients who are overprescribed opioids, as well as whether influences such as private versus public insurance play a role in providers’ decisions to prescribe these drugs. And, patient satisfaction metrics involved in billing may play a role in providers’ belief that they have to cater to drug-seeking individuals, resulting in overprescription.

Geographical variations in overprescription occurrence are of interest for several reasons. One important question is whether pain management is taught differently to physicians in areas of higher overprescription than in areas where the incidence is lower. Also important is whether continuing education for physicians and pharmacists is available and required. Headache patients’ access to headache centers and neurologists specializing in headache would be interesting to study. Clearly, increased overdose and overdose deaths in areas of low access to these resources are also a central concern. The effects of regulations in various locations, such as the presence or absence of Prescription Drug Monitoring Programs, as well as how robust or weak the programs are, will likely have an effect on the number of opioids prescribed. Related legal issues include how strict drug laws and law enforcement practices are, how likely drug diversion is to be prosecuted, and how big of a problem diversion is in a given area. Providers’ perceived risk of disciplinary action by state medical boards for overprescribing opioids may also be pertinent.

We risk atomizing if we reduce our view of the issue to some small portion of it. Simplistic popular adages such as, “It’s doctor shopping,” or “It’s pill mills,” ignore the detail that Americans are all at higher risk for receiving too many opioids. What is it about the United States and our healthcare system that has not just allowed but promoted this problem? Some would argue that any prescription at all of opioids for migraine pain constitutes overprescription. The use of opioids has been linked to medication overuse headache and addiction in headache patients, although the directionality of this association is yet unclear. Is there a reasonable standard of accountability in place for those providers prescribing these drugs outside of the guidelines for the condition they are treating? Some would further argue that doctors prescribing highly addictive drugs should be required to obtain certification in addiction medicine so they can properly follow their patients. It might at the very least be beneficial to examine the factors contributing to facilities’ relative responsiveness to current research and up-to-date regulations and guidelines, in order to encourage compliance in those places and individuals demonstrating irresponsible practices. Other countries’ and cultures’ philosophies on pain medicine should be considered as well. Given the abundant research indicating the presence of a problem, the exigent task at hand is to align patients and providers with satisfactory solutions.

Categories: migraines

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