Definitions matter: A taxonomy of inappropriate prescribing to shape effective opioid policy and reduce patient harm

Abstract

To date, no existing law or policy defines inappropriate prescribing, with only one state acknowledging the need for such a definition. At the federal level, a single provision of the SUPPORT Act of 2018 directs the Secretary of HHS to define inappropriate prescribing in a narrow context. Despite the expanding number of opioid prescribing laws, policies, and guidance documents, words like overprescribing, misprescribing, and over-utilization are used in myriad contexts with implicitly different meanings. This paper argues that defining inappropriate prescribing is a necessary antecedent sanctioning it. It may also improve policy by correcting for bias and other decisional errors. Using legal and multidisciplinary research, a taxonomy of misprescribing is offered with the categories of inadvertent overprescribing, corrupt prescribing, qualitative overprescribing, quantitative overprescribing, multi-class misprescribing, and underprescribing. The later three categories are less commonly considered in policy decisions, despite long standing evidence of associated morbidity and mortality. Particular attention is devoted the underprescribing category, which includes the predictable response by some providers to discharge patients without referrals, blanket refusals to consider opioid therapy, and abrupt or too rapid discontinuation of opioid therapy after years of use. These decisions are increasingly associated with significant harms, including patient suicides and poisoning deaths after patients turn to illicit sources of opioids — harms that are usually ignored in policy and law. The modest goal of this paper is to offer an initial framework to guide development and evaluation of prescribing policies in alignment with existing evidence of harm.