Pain is Personal
Proposal for Policy Change Removing Baseline Prescription Levels for Pain Medications
Zahra Jumani
Current Opioid Crisis
Opioids by definition are compounds resembling opium, a highly addictive substance, used to treat moderate or severe amounts of pain. Opioids ideally should be prescribed as analgesics for forms of pain such as end-of-life, or acute pain since there is limited research that states that opioids are beneficial in the long run(Mayo Clinic Staff, 2018). However, due to the lack of research specifically regarding chronic pain, professionals are often left with no choice but to prescribe the same opioids that they would for acute pain to chronic pain. This gap in opioid research has caused millions of wrongful over-prescriptions which have eventually led to a detrimental rise in deaths in the UK due to opioid overdose(Figure 1).
Although in past years “deaths have largely mirrored prescribing levels… in recent years there have been some significant increase in rates of death per prescription” (FPM, 2022). Mayo Clinic, a leading research institution in addiction, explains how it is the repetitive usage of opioids over time that builds a tolerance within patients, causing them to demand a higher and higher dosage to obtain the same effects. When these opioids are unobtainable from the original pharmacies at the high frequency the patient needs, they then are likely to turn to any other substance that may produce a similar feeling(etc. heroin), leading to more deaths due to unsafe drug use (Mayo Clinic Staff, 2018).
Descriptive Analysis
Despite the well-known dangers of addiction among patients and doctors, there is still a high number of wrongful over-prescriptions of opioids. To better understand why opioids are being overprescribed, a study analyzed 4,320 opioid prescriptions over the course of twenty weeks from the University of California, San Francisco Medical Center, and found that physicians were more likely to prescribe at the default level which had been established on their computer screen previously. In other words, those with an externally determined pre-set value of 5 were likely to prescribe 5 pills vs those with a pre-set value of 10 were likely to prescribe approximately 10 pills(Fernandez, 2020)(Figure 2).
Pain is Personal
The doctor's tendency to use the pre-set value is a prime example of how detrimental anchoring bias can be. Anchoring is when individuals make estimates based on what the given starting value is and then alter their estimates respective of that value. However, this can often lead to inappropriate adjustments, like in the case of opioid prescribing.
Anchoring can act as a mental prime and therefore lead to over-prescription as the anchor subconsciously primes the medical professional to a default prescription. Another study conducted by the University of Jerusalem analyzed various cognitive biases and found that anchoring bias led to clinical decisions being made on default treatment approaches rather than the patient(Meira, Esther-Lee & Freda De Keyser, 2021). The medical professional’s anchoring bias is also enhanced due to the mechanized nature of prescribing medication and highlights the individual’s conformity to automation. Many times when prescriptions are computerized, a doctor will adjust their recommended prescription depending on the automated baseline level, even though they may have not come to that decision without the subconscious prime of the anchor, in this case, the default baseline level.
Also, it’s important to note that overprescribing is far more dangerous than underprescribing and therefore the optimal option (Fernandez, 2020). Medical professionals succumbing to anchoring bias leads to dangerous over-prescription, but by removing the anchor of the default value, the medical professional would have to come to a prescription solely based on their interaction with the patient. Rather than wrongfully adjusting based on a computerized default value, if the patient was first considered when the prescription was occurring, there would be a drastic decrease in the over-prescription of dangerous opioids. The motive behind this proposed policy change would be to effectively remove baseline pain medication prescription levels inherently leading to a decrease in inappropriate prescribing due to anchoring bias.
This campaign, in simple words, proposes a policy change that would ensure that the prescription of pain medications, specifically opioids and other highly addictive drugs, should not have predetermined baseline levels. Medical professionals succumbing to anchoring bias leads to overprescription, hence removing the prime of the default value would diminish the repercussions of the bias. Removing the default level for prescriptions would make the prescriptions inherently more patient-centered and less automated. By removing the present anchor(the default medication preset) and setting a default value of zero, the medical professional has to “drop their own anchor”, which is then reflective of the patient and the professional’s interaction with that patient.
Furthermore, a previous case study done by the University of Toronto showed how framing can negatively impact the quality of care, regardless of whether the anchor is numerical or written. The case study explained how when the initial diagnoses were framed with previous information, medical residents were 25% more likely to commit errors than when diagnoses were left ambiguous until further consultation(Etchells, 2015). When the initial diagnoses were left ambiguous, the medical professionals were more likely to pursue their own diagnosis with the patient and come to a correct prescription, rather than sourcing their diagnosis on a presumption from the anchor.
This change to having a default level of zero would be more appropriate when it comes to prescription since the field of pain medication is still quite ambiguous, and many “conclusions about opioid efficacy, or the lack thereof, have been drawn from seriously flawed RCTs characterized by inadequate experimental designs. Data on the high variability in opioid dosage requirements and the high frequency of idiosyncratic side effects have been overlooked” (Nadeau, 2021, p. 11).
Final Remarks
By removing any baseline prescription amount, medical professionals are drastically more likely to overcome anchoring bias, improve patient care, and expose fewer individuals to opioid abuse and addiction.
On the patient side, if patients are being prescribed fewer opioids or similar medications that they are in need of, they are more likely to return and get reassessed. At each reassessment, the removal of the anchor would guarantee more accurate prescriptions for each patient rather than predetermined levels. As a result, this policy change would effectively diminish over-prescription, which is a lot more detrimental not only on the patient level but on the societal level as well.
Reducing the number of opioids in circulation hinders the patient from addiction and abuse, but also prevents them from possibly dispersing these opioids among others as well. Currently, “Over 1.5 million people with musculoskeletal problems receive opioids, and according to guidelines, 45% are over-prescribed, at a loss to the NHS of £100 million per year” (Shanahan, 2022). This policy change would not only save the lives of millions but also allow for a better reallocation of funding. By effectively, removing the anchor of baseline values, setting them to zero, and replacing it with the patient’s condition, medical professionals can more appropriately diagnose and treat patients while simultaneously decreasing the economic and societal burden of drug abuse and addiction.
Zahra Jumani
I am currently a senior at Macalester College planning to graduate Spring of 2023 with a major in Economics, a Statistics minor, and a concentration in Community and Global Health. I was born in Karachi, Pakistan, raised in the Chicago suburbs, and my passion is working in economic development and equity work.
