During the recent Interim Meeting of the American Medical Association, the organization’s president, Dr. Barbara McAneny, told the story of a patient of hers whose pharmacist refused to fill his prescription for an opioid medication. She had prescribed the medication to ease her patient’s severe pain from prostate cancer, which had spread to his bones. Feeling ashamed after the pharmacist called him a “drug seeker,” he went home, hoping to endure his pain. Three days later, he tried to kill himself. Fortunately, McAneny’s patient was discovered by family members and survived.

This story has become all too familiar to patients who legitimately use opioid medication for pain.

Since the Centers for Disease Control and Prevention published its guideline for prescribing opioids for chronic pain in March 2016, pain patients have experienced increasing difficulty getting needed opioid medication due to denials by pharmacists and insurance providers.

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More troubling are recent press reports, blog posts, and journal articles that describe patients being refused necessary medication or those dismissed by their treating physicians, who practice in fear of regulatory reprisal. At the interim meeting, the AMA responded to these developments, passing several resolutions against the rash of laws and mandatory policies that limit or prevent patient access to opioid painkillers.

The CDC designed its guideline as non-mandatory guidance for primary care physicians. But legislators, pharmacy chains, insurers, and others have seized on certain parts of its dosage and supply recommendations and translated them into blanket limits in law and mandatory policy. Today, in more than half of U.S. states, patients in acute pain from surgery or an injury may not by law fill an opioid prescription for more than three to seven days, regardless of the severity of their surgery or injury.

Although many of these laws exempt patients with chronic or cancer pain, in practice they often affect those with long-term pain, like McAneny’s patient. Some insurance companies and major pharmacy chains, like Walmart, Express Scripts, and CVS, also have mandatory restrictions on the opioid prescriptions they will fill. In addition to imposing supply limits, insurers and pharmacies are increasingly using the CDC’s dosage guidance (the equivalent of 50 to 90 milligrams of morphine a day) as the basis for delaying or denying refills for long-term pain patients, even though the CDC guidance is intended to apply only to patients who have not taken opioids before.

The Drug Enforcement Administration and some state medical boards are also using this dosage guidance in ways that were never intended, such as a proxy or red flag to identify physician “over-prescribers” without considering the medical conditions or needs of these physicians’ patients. As a result, some physicians who specialize in pain management are leaving their practices, while others are tapering their patients off of opioids, solely out of fear of losing their licenses or criminal charges.

The laudable goal of these laws and policies is to stem the tide of unprecedented overdose deaths and addiction in the U.S. But here are three interesting facts: Opioid prescribing is currently at an 18-year low. The rate of prescribing opioids has dropped every year since 2011. Yet drug overdose deaths have skyrocketed since then.

Recent data from the CDC suggests that illegally manufactured fentanyl, its analogs, and heroin are responsible for well over half of all overdose deaths. Stimulants like cocaine and methamphetamines are responsible for another third. Deaths related to prescription opioids come next in line, although many of those who died were not the intended recipient of the prescribed medication. In addition, most deaths involve multiple substances that are used in combination, often including alcohol.

The vast majority of people who report misusing prescription opioids did not get them from a doctor under medical supervision, and as many as 70 percent reported prior use of substances like cocaine and methamphetamines.

Conflating the misuse of opioids with their legitimate medical use, and treating all opioids — illegal or prescription — alike is stigmatizing patients for whom opioid painkillers are necessary and medically appropriate.

There’s no question that taking opioid medications carries risks: The CDC places the risk of addiction with the long-term use of opioids at 0.07-6 percent. The risk of addiction justifies judicious prescribing, trying other forms of treatment before prescribing opioids, and carefully screening patients for a history of addiction and mental health issues when opioids are being considered.

But most patients who use opioid medication for pain do not become addicted, although they may develop physical dependence. Addiction is the compulsive use of a substance despite adverse consequences. Appropriate medical use is just the opposite, use on a set schedule as prescribed with benefits to health and function.

Nearly 18 million Americans currently take opioids long-term to manage pain; many of them have complex medical conditions. When appropriately prescribed opioids are denied, patients whose pain has been well-managed by them may experience medical decline, lose the ability to work and function, and resort to suicide. Denying opioids to patients who have relied on them — sometimes for years — may cause some to turn to street drugs, thereby increasing their risk of overdose.

Dr. Terri Lewis, a researcher and rehabilitation specialist, recently conducted a nationwide survey of 3,000 pain patients. More than half of those surveyed (56 percent) reported disruptions in care or outright abandonment by their physicians. Among those reporting disruption or abandonment, many experienced adverse health consequences (55 percent) as well as hopelessness or thinking about suicide (62 percent) as a result. In other surveys, physicians said that they were prescribing fewer opioids or ceasing treatment of pain patients altogether because of regulatory scrutiny, even in cases where they believed that doing so would harm their patients.

The CDC guideline and its progeny of laws and policies have created chaos and confusion in the medical community. Some physicians are telling their patients that changes in the law are the reason they are tapering them to a preset dosage of opioids or off of opioids altogether. Yet the specific dosage thresholds in the CDC guideline were never intended to apply to patients currently taking opioids. Indeed, nothing in the current legal or regulatory environment justifies forcibly tapering a patient off of opioids who is doing well, and there is no solid evidence to support such a practice.

Some physicians are also using the CDC’s dosage thresholds, or simply their patients’ use of opioids, as a reason for abandoning them. Abandoning pain patients out of fear of regulatory reprisal may violate a physician’s ethical duty to place a patient’s welfare above his or her own self-interest. If serious harm results from abandoning a patient’s care, it may also serve as a basis for discipline or malpractice claims. In addition, physicians and pharmacies have responsibilities under the Americans with Disabilities Act not to discriminate on the basis of a patient’s condition, including chronic pain, or a perceived condition, as when a person with pain is erroneously regarded as a person with opioid use disorder or addiction when there is no clinical basis for that perception.

The AMA’s recent resolutions formally push back against what the AMA calls the misapplication of the CDC’s guideline by regulatory bodies, legislators, pharmacists and pharmacy benefit managers, insurers, and others. The resolutions underscore that dosage guidance is just that — guidance — and that doses higher than those recommended by the CDC may be necessary and appropriate for some patients.

The AMA also took issue with the recent practices of regulatory bodies that subject physicians to oversight and potential sanction solely because of the opioid dosages they prescribe. Medicine involves treating patients individually, and weighing the specific risks and benefits of treatment in each case. Taking this capacity away from physicians hamstrings their ability to treat their patients — as does requiring them to practice in an environment of fear.

Epidemics instill fear, but physicians have a responsibility to rise above fear and advance the interests of their patients. The AMA’s action in advocating for patients and for the right of physicians to practice individualized care is an important effort in beginning to rebalance the scales in the joint goals of reducing pain and opioid addiction.

Kate M. Nicholson, J.D., is a civil rights and health policy attorney who served for 20 years in the Department of Justice’s Civil Rights Division, where she drafted the current regulations under the Americans with Disabilities Act and managed litigation nationwide. Diane E. Hoffmann, J.D., is a professor of health law at the University of Maryland School of Law, director of its Law & Health Care Program. Chad D. Kollas, M.D., chairs the American Medical Association’s Pain and Palliative Medicine Specialty Section Council and is the medical director in palliative and supportive care at the Orlando Health UF Health Cancer Center.

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  • Something that has bothered me from ALL the way back in ’91,when I 1st started what would turn into a 14 yr odessey, to get the VA to treat my pain with something stronger than 800mg Motrin…which I finally achieved, after publicly firing my Dr in front of 50 or so veterans, the same Dr who prescribed me muscle relaxers for what I’d told him was at least bonespurs…which turned out correct, but also included a herniated vertebrae, as well as one broken all the way thru…and because of him I suffered in excruciating pain, which I was forced to self-medicate with alcohol…for SJX MONTHS before I found the right civilian Doc who knew what he was doing!…and for the next 13 yrs…I became the 1st,and only veteran of my generation to get his pain treated with opiates in the Knoxville, TN VA! Of course the dose remained the same…despite my efforts to get them to understand what titration meant…so I still suffered, but had no idea of how good I had it until they decided, in all their stupidity, that the new guidelines meant they should ONLY treat Vets dying from cancer…and cut me off without offering ANY alternatives.
    I suffer from very deteriorated disc’s in my back, lots of nerve damage, causing my feet to suffer tremendously, both my knees are a wreck, destroyed from Air Force surgeons…I’ve had my ulnar nerve in my arm trapped twice, causing permanent damage and pain…and to top it off I have fibromyalgia.
    I now have no quality of life, living completely sedate, on about a third of what I used to receive…from a civilian pain Doc. Of course there’s no access to medical marijuana, which would be a tremendous help for pain, my PTSD, and depression… I gave my health for my country, ALL 50 states, and over half of it has access, but because I need to live near my family, kids & grandkids I’m punished!
    To my point…where are all the rich, famous, & powerful people who have been mistreated like us…who if they were suffering would be fighting for us?!
    As in ALL things, I must conclude that the “aristocracy” are NOT having to suffer! Do you think Trump would be forced to suffer?!
    I’m only 55 yrs old…but because the amount of my meds the rest of me is suffering! I used to be able to swim…the one exercise I could do for cardio and keep my weight in check. I’ve lost 3 marriages where my pain has been a factor…now I fear nobody will want me…I’m broken…and it’s like living death. If not for my son I’d have nobody…and he works a full job, and despite his kindness I feel like a burden.
    Oklahoma is the 1st state to acknowledge that they got it wrong, and are changing how they treat us…but, as with every stupid prohibition..who knows how long the rest of the country will take to stop treating us like 2nd class citizens…this country where they won’t let a dog suffer… but let’s their veterans kill themselves due to the pain!

    • I know where you’re coming from. I’m a veteran too and currently have my senator involved. What surprises me is that the veteran service organizations have been silent through all this. DAV is actually promoting the VA’s solution to treat chronic back pain with acupuncture in the ear lobes. Mine all fell out in 6 days due to rolling around due to pain. There’s some Facebook Groups you should join. We need to stay united instead of divided and conquered. Try Veterans with Chronic Pain and Chronic Pain Suffers Ready to Fight Back. Let me share a post with you:

      A special note to Veterans. This was tweeted yesterday by Dan Laird, MD, JD — a rare professional with degrees in both medicine and law. I have his permission to share this on Facebook.

      Veterans w/ chronic pain who have experienced a bad outcome due to forced tapering of opiates or BZD: You can file a tort claim against the VA. It’s Standard Form 95 (SF95) online. NOTE:

      1) You MUST sign,
      2) Always ask for more than $1 million, and
      3) MAIL to Director of your VA.

      I think the reason for asking for one million is because you can’t receive a tort comp and a comp for your rating at the same time.

      I wish you the best.

  • I was on Methadone for chronic pain from DDD , 10 mg three times a day, I cut it down the last year to two a day. But now no more because of your stupid, excessive rules, now I am in so much pain, I don’t abuse my medication, but I am paying for it, and u wonder why the suicide rate is high. I now am on Percocet, 3 times weaker than methadone. Why don’t u go where the problem is instead of making patients suffer. NO HOPE, Thanks And no my comment wasn’t posted, so post it.

  • I too have had 3 back surgeries and have a back full of Metal from my pelvis to the top of my back. I have been on opiates for close to 20 years and have never abused my prescriptions. Now I have moved from California to New York. I met with a Pain Doctor here on a visit before the move and she told me to cut my dosage in half and I would be fine. I did so and when we got to New York she reneged and said she could only give me half of what she promised. I could not believe how reluctant she was to treat me even at the lower dose (5.0 morphine equivelant). These Doctors are afraid to treat the people who are not abusing the meds-what a shame that we have to suffer because the people who are abusing the system are either getting rich or dying. Here is my final statement. Medicare is being ripped off by these pain Doctors. All they want to do now is these injections and ablations. Medicare has paid $25,000 on my behalf with very little to no relief of my pain. This will help Medicare go bankrupt sooner than later. A few hundred dollars in pain medication would have done much better over these years. I know there are lots of you out there going through the same frustration. I just wish our legislators would look at the reality of whats going on here instead of jumping on the “Opiates are terrible”. bandwagon! In the meantime we just keep paying the price for the abusers who don’t want to use the self discipline that we do.

    • exactly.. but what gets me is.. they have opiates right there in the WH.. they have access but us slobs should suffer. i don’t understand how this works.. and i have seen this myself..
      people i know personally get the prescriptions and yet there’s absolutely nothing wrong with them. nada..zilch pain. and i know a few more that do the same
      why isn’t this patients and doctors being flagged or something? these people have been getting scripts for years.. but yet no therapy is any kind
      this is ridiculousl..
      in fact these people sell their scripts so how bad is their pain!

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