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.

advertisement

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 (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.

Leave a Comment

Please enter your name.
Please enter a comment.

  • I am seeking to sell my car to pay a lawyer to file a request for assisted suicide. I am allergic to all NSAIDs and Gabapentin. I can no longer take Prednisone because I can hardly see due to cataracts. I spent several years going back to my thoracici surgeon who lied to me. I have a neuroma. I can hardly speak each day, only about 10 minutes. I am no longer able to eat a full meal or drink too much liquid due to pressure on that neuroma. Given the fact this has allowe to grow for so long, only another chest surgery to remove the neuroma & nerves between the ribs but no one wants to talk about pain managment. They denied me pain management due to being on medicaid. They will do things to my tumor and hurt me more for lots of money but my pain is not any concern to any doctor at all. Therefore, I need to check out. I’m ready to go soon

  • I am all for what you said as a chronic Pain patient or basically not patient anymore considering. Not only did my insurance Dave my doctor away I’m over a year ago that I’ve been seeing for nine years for my pain and for my anxiety and so forth is actually addiction psychiatrist I’m not an addict but been on medications for more than half your life to become physically addicted to some of them. I was in school, working, living doing great until this! Now the doctor see is We need me at such a high pace! Long story short Not only is this difficult and I made and I am I’m going to have to get on methadone because no one will help me I also have PTSD and severe anxiety I’ve been on pain meds for 17 years and 30 just turned that I tried every treatment out there multiple times and that worked best and I was doing great and I take benzo’s for my PTSD and severe anxiety and I’ve been told I have the worst anxiety of any person ever like that they’ve ever met doctors have said those people who know me know if I’ve said this. But now if you’re on opioids even if you’re being weaned off extremely fast if you’re not weaning me off my benzo‘s so I’m gonna be losing both which I’ve been on in tandem since I was 16 so 14 years I have not once overdosed in my entire life I’ve never miss use my medication in fact even my asshole doctor and every doctor and that I said I am the most above board patient they’ve ever met and the only patient they trust my doctor the one I had last year and I had for nine years He took me with him pro bono to his private practice 3 years ago Because I couldn’t find someone to help me even the then. I have been responsible I never miss use I never have overdosed I’ve never run out I don’t lose my medication I brought them in for Med Counts, I’ve never failed a UA ext..
    It’s criminal what’s going on!! For the weaning process even started and when I lost my doctor year ago I was stressed out for the last four years because they kept taking my medications away or not being able to sell them at the pharmacy my doctor had to go around every freaking rule to get my meds filled or they would you make me do crazy shit to get them I had to do prior authorizations like every fucking week I had a pharmacist would kick me out of Walgreens but dry fucking hip surgery because he didn’t like him that I was on the opiates I was on a young age and this was at like 24. But wtf this has been hell for years! With the benzo’s I didn’t see that happening!!
    Whats happens is when I lost him my primary care helped me out and he started weaning me off slowly and then he referred me to this pain specialist( after a pain clinic didn’t work due to Them wanting me to come in weekly and I’ve already been in weekly and then wanted me to come back two days later when I have a horrible hip infection (I am immune compromised) and I get these horrible infection like 400 cm³ deep and I told him I might be in the hospital or I might have to see a a surgeon or have surgery it was that bad! I’ve had them had so many times I know when it gets bad and they’re bad bad bad( negligence iv always gotten neglected during these until I’m septic) but they said I had to show again that week to see the Main pain specialist there in like I’ve been going here for three months and I’ve never met him who the fuck what the fuck??? But they literally kicked me out because I was at the surgeons office and had surgery so I had to miss it) but he helped me ( ever since him that’s OK Chris is happened my Amarice miraculously changed he said to you what a miracle right why is it my pants on with her that’s not the only pain I have but why is that in Go away? That’s Not we’re all my pain is I have a lot of things wrong with me for long list but He now says it’s in my head that that’s where my anxiety and depression come from or I mean that’s where my pain comes from my anxiety and my depression I said no my depression is situational sad by both psychiatrists that I have have said I have situational depression I have had a hard life not just pain wise but Pain has made my life harder to I was it I had to work under the table you know as of 18 because I needed insurance because I have other illnesses too like..thyroid, anxiety,ADD, immunodeficiency compromised. ( still talk to Addiction psychiatrist that I can’t see because he’s private practice and my insurance won’t let me pay for my meds and they won’t pay for my meds even though I was going there for years and they did it but last year they just decided nope)
    will go to for a few months and wanted me to find someone else because he was retiring and he’s a dick too but now I’m being mean that in accelerated pace more than I have I think is not legal!
    Anyway wtf What happened to the Hippocratic oath?
    Awesome do they have an algorithm for people who have been on medications for as long as I have and have never over those that have never abused him and I’ve been on both in tandem or just even one and get them because there is this website Alina that my doctors use and one of my primary showed it to me and it was overwhelmingly scary like beeping like red blinking like overdose risk overdose risk like 900% but just cause of my doses it does t take my weight, age, tolerance and The fact that I’ve been on these meds for as long as I’ve been on and I have not overdosed and not abuse them and I’m not an addict and I don’t go through them faster than I should and I don’t tell them before I should ext.. why is there not even an algorithm for this???
    I honestly have thought more about Suicide this year then I have my whole life and I have PTSD so something really fucked up happened to me and I just want like I mean the major PTSD was something somebody would’ve filled them selves over it was so horrific but never until this year and I thought about it like for real. I don’t wanna live this way it’s not a life, it’s hell! Or I often fell in prison too not just cause I’m in to much pain to do most anything or go out hardly ever but my body.
    Thank you for caring!
    I wanted to know About a civil suit or stewing over this I mean the Hippocratic oath it is drugs are life-saving to me. And I lost them for no reason and now I’m losing another medication that’s life saving for me. Come on!!
    Just be more cautious doctors, have better screenings ext.
    And what I don’t understand is why our doctor is being sued anyway when people overdose when you give someone a medication it’s like having a contract with them that they are not overdose you know that you are to take the pills you were to take the pills accurately as prescribed if you take more and die that’s on you not only does it at the doctors office but you agreed to that when you get a prescription and at the pharmacy when you pick it up when he read the leaflet death is always on there and all in abusing an overdose he is on every prescription on for opioids and benzo’s so if you Abuse them or miss use them that’s on you not on the doctor and not on the drug companies that are being sued for making oxycodone and OxyContin! That I don’t understand either. Doctors clearly state and prescriptions clearly state how much medication you’re supposed to take her not to drink alcohol and not use other drugs with it so if you do that’s on you we can’t babysit people.

  • I am progressively getting worse in my pain since they have cut my dosage on which I was doing well – apparently at Kaiser the pharmacists implement this program – I was told that the FDA monitors them like crazy – what lies!

    • Yes they are lying to you especially since April a report came out urging Drs against misapplying their recommendations by forcing tapers when the patient is doing well on their dosage. Drs are making their own policies in fear of being targeted. Everything our Drs told us about our pain is now being back tracked and made to look less serious which should be a crime! Basically they’re telling us to suffer. They should be along side their patients fighting back instead of jumping ship.

  • I have never in 13 years of severe chronic pain treatment abused or over taken any prescribed medication. I try my best to always take less than even prescribed. My pain doctor left the practice and the new replacement flat out lied yesterday saying that the government required him to cut down on my dosage. This man has no idea what I am dealing with and consistently (throughout the appointment) downplayed the severity of my condition. I am livid with his attitude and lies. I don’t even know how to stand up for myself. If you try to speak up about a matter like this you are automatically thought of as being drug seeking. It is a train wreck hurting people every day.

  • im a chronic pain patient and my medicine has been tapered way down so I suffer bad for the last year tests show my back has many issues but my doctor is afraid of getting in trouble prescribing my medicine which isn’t right don’t know what I can do I shouldn’t have to live like this

    • I think the doctors should defend their patients that have went regularly and never abused their pain medicine. I am very disappointed in my pain management doctor. If I called myself that I would be embarrassed. I am so sorry that you are going through this too.

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy