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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  • every month my friend is denied her pain meds for every reason imaginable. Some pharmacists have told her they have the final desicion about her medical treatment. the pharm. she currently uses have left her without her pain meds. for 2 weeks. She has often thought suicide. Even,at 72yrs thought heroin. ?!!!

  • I have had chronic pain since 1989 and have been off and on medication sines then mostly by my choice. When pain was improved I stopped on my own. Recently I tried to get surgery the insurance won’t pay. Before that doctors said surgery may make it worse so wait until you cannot walk. I tried to get spinal stimulation the insurance declined. Still I get rhizotomies , epidurals and steroids no long term relief. Yet my doctor keeps cutting my dosage from 60 mg to 20 mg hydrocodone w acetaminophen. Now to make it worse my insurance will not pay for opioids. Of course the problem gets worse as I age knees need to be replaces shoulder and elbow hurts and as the pain increases I get less and less relief. What’s next?

  • My mom has stage 4 cancer the pain is obvious when in the hospital she was given hydromorphron while testing and chemotherapy. In order to get radiation they told her she needed to be an out patient. The hospital sent her home with hydrocodone and Tylenol and radiation was a week later. They would not give her hydromorphron even told her it was only available intravenously. Not true. Three days later she was back in hospital. It was a choice go home without pain med and wait for relief from radiation or stay in hospital on pain meds without treatment. This is insane.

  • I too would love to join a class action suit. As my pain clinic reduces my prescription amount my blood pressure increases. My recent MRI shows my spinal cord is dangerously compromised. The general public only hears about THE OPIOD CRISIS…not one news story states “cronic pain patients” have had their quality of life taken away. The only hope is to take this injustice to the courts. I’m nearing 74, my “golden years” have been taken from me. what happened to mercy?

  • Please contact me personally. I am a 2L at FAMU Law in Orlando, and chronic pain sufferer who is having, a tough time with the medical issues addressed in this excellent article.

  • I am one of the people with chronic pain that has been forced tapered and now denied any further pain medication refill. I have been on opioids for 14 years of successful pain management treatment. I have tried many other modalities without success and the only thing that helps and allows me a life of any kind is the medication. The record shows I have never abused or misused my medication in any way. here in Kentucky they are misapplying the CDC guidelines completely and doctors and clinics fear lawsuits if they prescribe for anyone other than cancer patients.

  • Good day. My pain doctor illegally charge me $100 a visit for multiple years when I had insurance. Since I have multiple spinal cord injuries, 2 past histories of lumbar fusions including one that was botched leaving me with three fractions and another lumbar fusion to correct the first one. Since then I’ve been hit by somebody under the influence and my fusions are failing. I will need some type of lumbar correct of surgery and a thoracic ablation, I’ve been on pain management for many years after surgeries except when surgeries were successful. My recent pain management doctor’s partner was using my urine for other patients. Upon seeing his partner because he does physical therapy, his partner tried to tell me I had a negative urine specimens and he lowered my medicine. I saw him again and he told me, I had a negative urine sample & lowered my meds again but unbeknownst to him I had the nurses do a swab which of course came out positive for opiates. (thankfully due to my healthcare profession, I made sure to get my mouth swabbed by the nurses which proved the urine specimen was incorrect). That was not my urine. I’ve been a solid patient of those doctors for many years. Once this happened with his partner all of a sudden he wanted a referral, no payment for the first time out of all these years and then he, the doctor I’ve been seeing and in charge, trying to get rid of me, decreased my medication by 1500 mg in just a month’s time leaving me obviously incredibly sick and unable to adapt to such a lower dosage. I need corrective Lumbar surgery and can longer take care of my day-to-day needs. I have Trumatic spinal cord injuries unlike many of the patients who go to his office. I cannot get the lab to cooperate and give me results in order to see another pain doctor. this office also switch labs after my specimens came back incorrect. I am in the middle of trying to get some type of correct of lumbar surgery and a thoracic ablation. Unfortunately, he has taken me off my opioid treatments I’ve been receiving on and off for 15 years in between surgeries and over periods of time. I can no longer function take care of my family I don’t have much time left. I would like to see this new neurosurgeon but I cannot make appointments because injuries I sustained causes chronic pain and I cannot function. There are multiple other unethical behaviors & possible illegal actions in this office. As a former RN who would love to work again & get certified as a safe RN has seen the types of patients in his office who have money. I cannot find Help or Pain Management after seeing him and do not think I could live much longer. Unlike the majority of his patients, I have serious injuries requiring pain management and physical therapy which was promised to me and never given to me. In the end he left me sick incredibly sick withdrawing from opioid treatment while suffering from Trumatic spinal cord injuries. Before I die I want to report him to Medicaid, America medical board and the American Pain Association and the DEA. I do not have much strength left. I cannot find a doctor to treat me since I believe he red flag me/tarnished my name and left me incredibly sick withdrawing from opioid treatment while suffering from Traumatic spinal cord injuries (The Incompetent talk to said he would call in Suboxone and for a week straight or more my insurance company (which is documented) and I called The unethical pain management doctors office every day to see if it was filled so I wouldn’t have to go through with drawls with my broken back and his office never called my insurance to have it authorized. My insurance, Weil conference me in, called and with the person who authorizes the meds and they lied to the insurance company and me and said they submitted the paperwork which they never did. My insurance company assured them for 7 to 10 days they have not received the necessary paperwork to have emergency Suboxone authorized. I should not be on Suboxone I am a cripple with traumatic spinal cord injuries as well as other healthcare conditions such as rheumatoid arthritis etc. A Sociopath would leave a person/patient suffering the way he has made me suffer and continues to make me suffer since I cannot obtain pain management with physical therapy. Before I die I want to report him to Medicaid the American medical board the American Pain Association and the DEA. I do not have much strength left. I cannot find a doctor to treat me since my previous doctor may have soiled my name as a drug seeker. Yes I would like this doctor to feel pain I feel every day and not be treated because that’s the point. My urine and all my test I’ve always been so good, leading me to believe they may have then use by my pain doctor and his highly incompetent unethical partner which caused me to make the nurses SWAB me so I can show the other doctor that was not my urine specimen because my swabs all came back positive for opioids. Opioids Last longer in urine samples then swabs. My swabs came positive for opioids, my urine came negative which is scientifically impossible. His partner had the colossal audacity to tell me that forensic labs do not make mistakes. I am studying to be a sexual salt forensic examiner RN. But I cannot continue my studying because I can’t even shower. I’m sending you this text now so somethings documented in case I can no longer go on. I would’ve liked physical therapy while on opioid treatment in order to build up the strength of my body for whatever hopefully conservative treatment that could fix my failing lumbar fusion and procedures such as an ablation required on my thoracic spine. I appreciate your assistance and I thank you for the platform. Whatever happens to me may help somebody else someday. It’s killing me that I cannot take care of my family rendering me Useless and a non-functioning mother nurse wife Advocate etc. Thank you very much. I can be reached at 917-623-1431. I always return voicemails. If I can’t get to my phone it just means I’m in another room and having difficulty getting there. By the way since this doctor treated me unethically and did harm to me I have fallen on my face in the subway on the handle of the cane flat on my face spread out like Jesus Christ leaving a huge bump on my head, unstable and possibly passed out. I fell in the tub multiple times with help. It’s not even like I am a human being anymore. There is a difference between a drug seeker and a person with a chronic spinal cord injuries or other chronic injuries that caused immense chronic pain every day of their lives. When this professional doctor lowered my medicine 1500 mg within a month I, of course got sick because I did not have enough of medication which has been lowered multiple times before and I was just making it but no more. While in his office I observed this Pain Management’s office take money and hear the nurses say to two patients, which seem to have a lot more than $100 in cash, “here is a three month supply of opiates”. I have dates, Notes and information including the LAB that will not cooperate with me and give me my medical records which I requested properly, in writing, with ID (Plus I have emailed the live 3 to 4 times and called them multiple times with the promise of a phone call back which is never happened nor have I ever received my right to my healthcare record of the lab with negative opiate urine specimens for me and positive opiate swab records). I have the right to all my healthcare records dating back since the day I was born. Please excuse any typos or grammatical errors. I am using voice text. Obviously I cannot type. Again thank you and I appreciate the ability to speak with someone. Patricia Donato

    • Ms.Donato,,,believe it or not,,your case may get worse!If I were u,,,get your medical records asap..Doctor’s are literally changing medical records to justify denial of our medicines now,,,After a 18 year,”mis-diagnoses,,finally ,,a surgeoun and a new primary diagnosed chronic pancreatitis,w/lipase level high and a gallbladder and I quote,,that looked like a dam gravel pit,,well here come the cdc guideline,,these assh-les literally went in changed it to ,”constipation,” changed my ultrasounds,,my name on someone elses ultrasounds,,I have all 3 to prove it,,,and now the physical pain from pancreatits w/barely any medicine,,oh and the scaring on both lower lungs ,,is now labelled as my boobs,,,just soo they can justify barely any medicine,opiates and not get sued for failure to diagnose,,point being,,,get your recods ,,they will change them to justify no medicine,,,disgusting aint it?!Alll for 1 man named Andrew Kolodny a shrink,,who has done soooo much damage to the field of medicine,putting is backwards to the 1800’s,,,yet doctors just let the shrink keep doing,,arresting innocent doctors,killing patient,torturing patient,,all in the name of Andrew Kolodny and psychiatry..Psychiatry has a long history of abuse unto the medically ill,,yet,,,those who could of stopped him,,didn’t..I guess they like their collegues,patient loosing everything in life eh??maryw

    • If u find a lawyer,[s]’s,,,,get back to me,,,for we have tried to find a lawyer,several times,,soo if u find 1,,we have in writing over 20 different laws,csa,ada,cfr’s,,, this government has willfully broken and has broken every single treaty they have ever signed against torture,torture in the healthcare setting,even genocide,,,soo u let me know if u actually find a lawyer who has the balls to do whats right here,,,,maryw

    • Would join class action against CDC for not doing proper research before
      Issuing opioid prescribing recommendations/rules.

    • You are more than welcome to contact me, and/or use my name and information to be included in a Class Action lawsuit. I have been on opiod medication for about 7 years. Due to back and hip surgery, DDD, Spinal stenosis, arthritis, and my meds half been either totally not covered or issued, or cut down by the dosage so much, I can take one pill a day. My medical records are clean as a whistle. never a missed pill count, no dirty urine, no abuse or negative side effects, yet the Dr., in accordance to the new CDC regulations, has cut my medication down to almost nothing. If my case will help this problem, I’m all for a Class Action Lawsuit. Thank You, Paul

    • Have suffered from multiple health issues since I was 11. Always endured the pain, screaming into my pillow.
      At 55, and new chronic pain issues not being adequately treated for the last several years and multiple drs and medications that didn’t work, I’m tired. Depressed, feel more of a liability than an asset to my family.

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