This article examines current policy and practices that emerged in response to recent increases in opioid related morbidity and mortality. This is a serious public health problem; however, the issue has been framed narrowly, and inaccurately, as the consequence of opioid abuse alone and directly attributable to inappropriate prescribing practices. These claims are analyzed against existing data and placed in the context of the negative impact on the well-being of individuals with disorders such as chronic pain, substance use disorders, and mental illness.
Many of the policy responses are not aligned to the real and potential harms — the premature death or increased morbidity associated with opioid misuse and substance use disorders. Instead, too many efforts focus on reducing prescription opioid use absent context and include heightened criminal enforcement and restrictive state legislation. Practice level responses focused on enhanced risk management approaches (treatment agreements, random urine screenings, reduced opioid prescribing even to those whom benefit) at the expense of holistic patient care. These are reviewed in light of available evidence. The risks of other types of harm, such as suicide and morbidity associated with mental illness, are compared to the actual risks of opioid misuse and diversion and suggestions for coherent policies and practices are offered.
The ongoing and possibly worsening environment for patients in pain is evaluated in terms of various well-studied cognitive biases and distortions that can lead to faulty policy making and practice decisions. Policy and regulatory responses are examined, both in terms of the possible influence of decision-making errors and of the operation of availability cascades and outrage heuristics. From this context, the current and proposed law and policy is examined in terms of its coherence or “fit” to the problem it purports to address. The specific application of literature of cognitive distortions and biases to decision-making errors in this particular context is a new contribution to the area. I advance that decision-making errors by policy makers and providers are probably a contributing cause of the unnecessary and unjustified suffering of patients by reinforcing incoherent and fragmented approaches. Finally, those policy approaches that do reduce harm and serve to enhance the well-being of these vulnerable populations are evaluated.