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Opioid Exceptionalism – why these drugs are different than all others

Greetings – David Deitz here. Joe has kindly offered to let me provide a guest post on the latest report on the opioid epidemic from the National Academy of Sciences, Engineering and Medicine (NASEM). The report is available here. It’s also 389 pages long in its current pre-publication form, and because I think there are some really worthwhile parts relevant to many of you who follow MCM, I’m going to give you my summary of the highlights.

The quick take – opioids are fundamentally different from other drugs due to the harm they can cause – and the FDA should consider this when addressing opioids. (JP observation)

Why is this report important and why should you care? Well, for one, the opioid epidemic is a true, deadly epidemic, that has left few areas of America untouched. As NASEM puts it (emphasis mine):

Current national trends indicate that each year more people die of overdoses—the majority of which involve opioid drugs—than died in the entirety of the Vietnam War, the Korean War, or any armed conflict since the end of World War II.

That’s about 90 a day. Every day. I don’t think that’s “opioid hysteria”. And WC has a lot of reasons to care, since analgesic drugs, most of them opioids, are the principal drugs prescribed for occupational injuries.

It’s worth noting that last week also saw the release of the interim report from the President’s Commission on Combating Drug Addiction and the Opioid Crisis. This report urged declaration of a national emergency – more on that below.

As many of you recognize, this is an incredibly difficult public policy issue, in which the legitimate needs of millions of patients with acute and chronic pain must be balanced with the harms opioids create. The earlier IOM report on pain in 2011 really punted on this one, but the NASEM gets right to it in the introduction:

  • How exactly does a regulator….balance, for any particular regulatory action limiting access to opioids, the otherwise avoidable suffering that patients with pain would experience against the harms, not only to those individuals and their families but also to society, that would be prevented by the restriction? (pg 1-16)

The answers from NASEM are brilliant, well-reasoned and based on large servings of evidence – not only on opioid harms, but also on efficacy for chronic pain, likelihood of use and abuse in different contexts, alternative treatments, epidemiology of addiction and value and availability of various opioid addiction treatments, to name only a few. One of the most valuable concepts going forward is the doctrine of “opioid exceptionalism” a term coined by co-author Dr. Aaron Kesselheim in the NASEM webinar (you can get the slides here).

Put simply, opioid exceptionalism means that the FDA, as well as other public agencies, should go beyond the risk/benefit paradigm they currently use for new drug approvals that is based on individual patients and consider the implications of an individual opioid to patient’s families and society.

In other words, public health considerations need to come in because the societal implications are so large for this category of drugs. Drug manufacturers and some pain management professionals (and probably, libertarians) aren’t going to like this, but I think NASEM makes a compelling case that business as usual isn’t going to reverse the trends. They don’t really mention the workplace much as part of the public health discussion – there’s an opportunity for ACOEM to push up to the table.

I won’t review all of NASEM’s public policy recommendations, but some have implications for WC, including:

  • Improved reporting and data collection. This has to include WC if it’s going to be complete.
  • A call for insurers to reimburse for comprehensive pain management, including interdisciplinary approaches. Many in WC do, but it has to get better.
  • Better patient and public education about opioids. Again, a role for WC here beginning at the first emergency department or occupational medicine clinic visit.
  • Expanded treatment for opioid use disorder. There are cost implications for employers here, but it’s the right thing to do.

Meanwhile, the President’s Commission mostly agrees, and provides some of the same recommendations. Unfortunately, there are some thorny political problems with that emergency declaration (which I agree with) – it’s difficult to reconcile recommendations to “rapidly increase treatment capacity” and expand benefits for substance abuse treatment with cuts to Medicaid.

The NASEM is the meatier of the two, is better thought through and overall is one of the most comprehensive public policy documents I’ve read in a while. Take a few minutes to look at the slides, they are a good summary of the recommendations. Where do they touch your organization?

Let’s not just hope that the NASEM report makes a difference, but do what we can to ensure it.

David Deitz, MD, PhD is principal of David Deitz & Associates, a healthcare consulting firm based in Massachusetts.


8 thoughts on “Opioid Exceptionalism – why these drugs are different than all others”

  1. Despite Mr. Dietz’s comment regarding Libertarians (I am one), I’ve worked in the Insurance Industry for 2+ decades and agree with most of the comments above.
    It is clear opioids are not appropriate for long term use (over 3 weeks) in most cases. However, I continue to see a minority of physicians (mainly the same individuals over and over) flatly refuse to consider alternatives to long term use of these medications that, in many cases, have left individuals a shell of their former personality and potential. Particularly disturbing is the long term impact overdose and/or death has on immediate families.
    Holding the source responsible, prescribing physicians, would result in the immediate reduction in opioid prescriptions and the adverse results of these medications.

    1. Brad – I meant no disparagement to libertarians! It is merely my sense that the libertarian view is usually focused on individual freedoms, and that a public health approach may sometimes infringe on an individual’s access to opioids.
      No argument that prescribers need to be held responsible when over-prescribing is egregious. DD

  2. I am in complete agreement with the thoughts and Dr. David Deitz’s challenge to our industry to “ensure” NASEM’s recommendations get “implemented”. One challenge is somehow coming up with an appropriate methodology to provide “some relief” to physician providers from the “burden” placed on them to achieve high “patient satisfaction” scores since many of them have their compensations linked to this arbitrary rating system. Deming’s premise that our “output” is truly a function of what our system has been designed to do. Hence, we have to look at how to address the faulty system issues leading to this unfortunate outcomes. A tough problem… but solvable if everyone truly wants to manage it right! And get focused on appropriate outcomes…

  3. Michael – thanks for the support. On the patient satisfaction issue, NASEM does take up this topic, in discussing how patient satisfaction scores along with the Decade of Pain have contributed to the problems. DD

  4. David, thanks for sharing. While admittedly the exception, I do see a select number of individuals who seem to benefit from a moderate opioids dosing resulting in less pain, more function, continuing to work and general better health and happiness.

    While workers’ compensation selectively does allow for some biopsychosocial functional restoration treatment approaches, with some exceptions, such approaches are difficult to get authorized.

    For the most part, our IW patients are better not getting on opioids and if on them, getting off them quickly.

  5. I really appreciate this summary and highlighting these potential resources to combat the opioid crisis, if not epidemic. The limits and boundaries of patient and public education is an especially tricky one. Urgent care patients in Denver are frequently asking about using cannabis to deal with moderate short-term pain, and some of them even mention a hesitance about opioids as one of their motivations.

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Joe Paduda is the principal of Health Strategy Associates



A national consulting firm specializing in managed care for workers’ compensation, group health and auto, and health care cost containment. We serve insurers, employers and health care providers.



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