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.

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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, and a former Mayday Scholar. 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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  • I’m so glad to see this article .I became very sick in 2016. Just in time for all the wonderful experimental medicine that did not work .I had ACDF of my C – spine with four impinged nerves I lost My left are and they left me in horrible pain .The surgery did not work on c spine 5 and 6 I have nueroforaminal stenosis on both side I had my lumbar go .I have constant head pain Arm oh yea after the surgery I have a frozen shoulder nerve pain in both arm and Hansd also nerve damage in lower legs and feet and bi lateral sciatica.I have know life I’m luck when I take a shower .Like everyone else my social life is going to the Drs who don’t care.I have some pain medicine but not enough to walk or drive my car .They have me set up with the ride for Drs appointments .I feel as if we are being tourcher everyday .I have a pain councilor .I hate this preaching from people who have No pain . They have know idea what it’s like to be in bed with the sun shining in you face and your screaming in pain .I want to hear a Dr say to all of us how can I relieve your PAIN ?

    • Lisa, What State do you live in? I am guessing Midwest, Nortwest or Connecticut.
      Hopefully this year many will come to understand that the PROP consultants tried to generate revenue by lying to CDC in order to gain from sells of buprenoprine (suboxone) and have everyone in pain line up at Addiction Centers for America. FDA NEVER approved the guidelines and the only reason they have carried any weight is the fact that they are written with CDC letterhead.
      The CDC has strict guidelines that prohibit consultants like this from trying to profit by suggesting ideas, submitting fake or weak reports that are not scientifically founded.
      Pick up the phone and call your congressperson TODAY!

  • Hoorah. Someone is finally growing a pair to push back at this blatant case of Nazism pushing in to medical treatment. I’ve suffered from chronic pain due to multiple diseases for almost 30 years and finally about a year ago achieved a balanced level of about 7 on the 1 – 10 pain scale. I wasn’t what you would call functional nor enjoying a fulfilling quality of life but, I could live with that level. The level depended on an interthecal pain pump supplying morphine and a local anesthetic into my spine and 4mg of dilaudid 4 times daily orally. Now with the CDC guidelines run amok my Pain Specialist has reduced the dilaudid 50% in my last 2 visits and indicated that the powers that be will be targeting my pump dosage next. He doesn’t really have a choice in the matter with a thriving practice and many patients he is scared to death of being put out of business. Already Walmart refuses to fill his pain prescriptions. But now my pain levels are getting out of hand. Just 2 weeks ago I found out I have two vertabrae that are now bone on bone which is pinching nerves causing another layer of excruciating pain above all I had before. I am just one of the 50 million chronic pain sufferers estimated by the CDC, sufferers who are or will be adversely affected by the out of and out of context application of the CDC guidelines.

    • This government and others need to stop punishing pain patients immediately. It was always a deeply flawed practice on their part and can only make matters worse. As they are finding out through their research, it is only a small fractional percentage of chronic pain patients who are abusing their opioid pain medicines. There is way to much sympathy towards abusive addicts and not nearly enough were it should be directed, real honest pain sufferers.

  • Thank you for posting this…I hope more legislators, politicians, etc wake up to the actual facts. Not the hype, inaccurate numbers, possible profits motivating some politicians, etc.

    Best article written so far on this subject! God Bless!

  • What we are dealing with is a bunch of opioid phobic physicians that have been taught that they are evil. How many doctors consume Jim Beam, Jack Daniels, wine and other alcoholic remedies?
    Many pain doctors have no understanding of geriatric medicine or the pain associated with getting old. Their day will surely come. I
    I am reminded of an epitaph I saw on a grave marker. ” Where you stand I once stood, where I am you will someday be. And that day is a lot closer than you think.”

    • Exactly what I’ve been saying. If opioids are an epidemic, then what do you say about alcohol? Every day I see horrific stories about innocent people being killed by drunk drivers, and lots of others catastrophically injured. There are more deaths from alcohol than opioid medications and ironically, alcohol is present in the system of many of the overdose deaths that are being attributed to by opioids, yet that part gets convienietly left out. I’ve known so many more people who have died or had their life and that of their family ripped apart by the misuse of booze. Alcohol is taxed and brings in billions so it’s ok, it’s off limits. Another fine example of the total hypocrisy of this misguided crusade against cpp.

  • I’m happy to report today I finally got my one pain med in hand filled by express scripts via mail. The two prior authorizations required are approved for one year. After a hundred plus phone calls, a board complaint, etc., my condition has flared just in time that I might be able to get on top of my pain so that it doesn’t escalate any more. My fingers and toes look like breakfast sausages cause their so swollen. My hands are bright red with open lesions due to my psoriasis gone wild with my scalp completely raw around my face. This just should’ve never happened.
    Stress for all pain conditions makes our pain worse. Had someone just did their damn job now 3 weeks ago more than likely this flare wouldn’t have occurred or if it’s did it would’ve of been this extreme. So onto taking 100 mgs of prednisone and tapering to hold at 20 mgs forever and watching my bones get sucked of all the good stuff, my teeth cracking in half due to calcium depletion and my hair falling out in chunks (although my hair has been growing back for a year due to taking methotrexate I haven’t lost any in a year) which I contribute to stress.

    My chronic pain suffering friends we have to ban together and write to your local aclu, file complaints with the office of civil rights, file board complaints, etc.
    my leave was spared and everyday one if us is contemplating, planning or taking their leave due to over zealous politicians, scared physicians who fear their licenses will be revoked, pharmacists playing god and a MD who we did not authorize, etc, etc.
    today I gave the strength to write this but I don’t know what tomorrow will bring just as you don’t. Do when u do have that energy to fight for you, you need to do so.
    No more suicides due to refusing to fill medications or tapering off meds which results in no quality of life! No mote suicides for anyone not being able to control their pain!
    We must stick together and lift each other up !when lance responded to my first message and then others, it gave me the strength to pull myself out of the dark cloud just long enough to get my mind right and not try to take my leave again. We suffer in silence but please know there are people here who hear you, see you and know that you are important to someone somewhere and if you don’t have anyone, at least know you are important to me!

  • Had appt with pain doctor here. Won’t prescribe methadone cause I’ve been off it for more then 10 days. Gave me a script for norco. Went back to the Walgreens to fill and mr. Chad said that Walgreens will never fill a prescription for me again no matter what it is. Can they do that? Further stated his cause by saying I ensured there are detailed notes in your file. Excuse me? I asked for my records and he said he dosent have to provide them. Isn’t that against HIPPA? That part of my medical records right? Found a pharmacy to fill the Norco. Express scripts finally approved my methadone after two prior authorizations for the medication and for quantity and utilization reviews but won’t ship til Monday. Filed the complaint with the Mississippi pharmacy board and they responded back within 24 hours saying that pharmacists have the right to refuse. Have that in writing from their attorney. Getting the ACLU complaint together. Any advice on how to write the complaint do that it is not immediately rejected?

  • I started to type out my long sad story. After reading some of the comments I can see I am not alone. My Dr, for the second time has reduce my pain meds and I’m sure his plan is to take them away entirely. When I discussed the first cut back with him, his reply was that pain meds are not for long term care. I go to a pain Mgmt Dr.since I have and will always have chronic pain. It was my feeling that a pain Mgmt Dr. understood that certain injuries result in life long pain and could understand that even doing the necessities in life become impossible w/o my medications. I have been on pain meds for 5 yrs and did my research years ago to understands the pit falls of pains meds. I have always treated them with the utmost respect for the dangers of long term use. I don’t understand how the gov’t can dictate to a pain Mgmt Dr that he is to take patients off their pain meds. I have had to adjust to having no pleasures in life but grateful that I could at least perform necessary functions to exist. To add insult to injury my pharmacy marked up my prescription by an 87% increase. They said it is a federal law that went into effect January 1, 2019. I took time to read 205 pages of the new Fl. law, HB21, that went into effect. The first 12 pages dictate what rules a Dr. must follow. The rest is to put the fear of God into Dr. on criminal prosecution if they do not obey. In a way I feel bad for Dr’s who want to follow the oath they took but the fear they feel from the gov’t. For not following their opinion. None of who are doctors made up these new rules. The gov’t is feeling the pressure of doing nothing about addiction for a decade. Now they make up Law’s that are only hurting patience in real need. The addict will always figure out how to get high while truly in need patients suffer. I have spent days laying in bed in pain and it was somewhat comforting to know I am not alone. Sucide is not the answer to relieving pain. I just pray their are people out their on our side trying to correct this injustice.

    • I know exactly how you feel. I have seen a pain doctor since my last back operation in 2009.i am disabled and I have followed instruction from my doctor to the t because I knew the consequences if I didn’t would basically end my life I believe.my doctor now because of this war against patients who have towed the line im mostly confined to my bed.i have considered the worst but keep hoping this nightmare will end.

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