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 had a life until they cut half my meds. I feel like my constitutional right are being compromised because we have a right to pursue happinesz which is impossible when i am in severe pain. What legal action can i take?

    • Brenda, so many people like you are in a terrible position with all this suffering. Its just heartbreaking how you are being treated. I only have one answer for you and I am certainly not trying to force my beliefs on anyone but what you can do if you are open to it is ask the Holy Spirit to help you in the name of Jesus Christ. He sent him here to be our comforter and helper. There seems to be no other recourse. The Holy Spirit will help you all get things right.

  • The problem here is that if the Gov doesn’t show that it’s not ok for doctors to prescribe all the opiates that their patients want, then it’s not doing it’s job protecting the public from kids that get a hold of the drugs in the parent medicine cabinets and the abuse from some of the people claiming to have pain when in fact they are just either using the drugs to get high or selling them on the street for money to buy heroin with.
    It’s a sad fact that this does occur and it occurs more than any of you know. The Gov understands that you are in pain and while it’s actually stopping doctors from prescribing the drugs, it’s putting the fear of losing their license into them and prosecuting the ones that have been over prescribing.
    As for addiction… I read someone on here that said that the lowest dose they have been in on decades was 3 X 30mg oxy tablets a day and that he is not an addict. I will tell you that if you are taking 3-30’s a day, you are addicted to them! Also, if that’s the lowest dose you have ever been on, then you were taking a lot more in the past which also means you are addicted to them.
    What they don’t want is addicts. Upon withdrawal the pain that you have gets worse. In some cases 1/2 the pain you experience when you don’t have the drugs is directly caused by the drugs leaving your system and your opiate receptors don’t like that.
    I tell people that they should look into Suboxone as it works to keep you free of the opiates that people are abusing and it helps with pain as well. There are a few variances of the drug made by others that will help some of you with pain as well.
    Trump doesn’t have anything to do with this. This was going on long before he got into office. It just wasn’t as widespread. I knew it was being implemented 5 years before Trump even considered running for the Presidency.
    What they don’t mind giving is as many opiates as one wants for anything terminal. They figure that even though you will be an addict, you won’t be around long enough for it to make a difference. The thing is, lots of the prescription drugs on the streets right now are from the people that are terminal and are selling them to afford other things since most of these people can’t work anymore and the demand is high due to the Gov putting out there “recommendations” on prescribing opiate. So they are creating their own problem then recommending ways to stop it. It’s a circle that will never end. Someone needs to come up with a way to combat this on all ends and all at the same time. This will allow people in pain to live their lives and the people in power to keep control of the drugs. Unfortunately I have no idea how to do this or I would have already been writing letters to people to inform them of a method to do exactly that.

    • What u speak of,teenagers,addicts,,,again,,unless there is a legal prescriptions ,,thus they have an illegal drug on/in them.The problem could of easily never happen’d w/those of us in chronic physical pain from medical illness being denied access to our medicines opiates,if our government honored our constitution, which states,it is illegal for ANY GOVERNMENT agency,to practice medicine,,,including the dea..Furthermore,,,have u ever had a ,”drug” test,that does not tell u the amount of metabolite/drug in your system??No,,The cdc is lieing,,when it states opiates KILL 41,A DAY… for they claim if there is literally 1 nanoscamm in a person body of a opiate,,,,they blame a opiate for propaganda purposes.I have asked the cdc for any data on how many die from taking their medicine opiate as p[rescribed exactly as their doctor has written,,,THERE IS NO SUCH DATA IN EXISTANCE,,, thus,,,no-one dies from taking the opiate medicine as their doctors tell them,,maryw

    • franbush here in michigan we simply cure junkies with 20cc air bubble 1 an done demand is slowing but much needs to be done

  • I’m 70 years old and a cancer survivor. Half of my colon was removed and I was given a experimental chemotherapy in 1990. I was scheduled to take the chemo for a year but within 2-1/2 months the chemo was destroying the nerves in my legs, feet, hands, arms, and all over my body, that is when I decided that I would rather die than continue the chemotherapy. I had the cancer when I was 40 years old and didn’t take any pain relievers for years until I was 64 years old, that is when the nephropathy (CIPN) began to worsen and I began taking pain pills. The pain was getting so severe I could not sleep without pain medications. I have been on a regimen of pain pills that has been lowered twice since this insensible approach at lowering the death rate of opioid abusers. What no one seems to understand is that pain relievers lose their efficiency over the years and soon they no longer provide the same level of relief. Older people who many times have multiple health problems and desperately need pain relievers to have some quality of life in their later years. It seems to me to be a cover up of the ability of the Government to stop illegal drugs so they lump everyone in the same category in order to make it look like they are making progress on the “War on drugs.” I believe and I think there are many more people like me that would rather have a “Quality of Life” with some possibility of dying a few years earlier than to have a long miserable, and painful life. These laws, assisted by the thoughtless news media, haven’t given a thought to the many people who will suffer the rest of their life because all the public heard was that people were dying from drug misuse. There was very little thought or research put into these laws before they were made, and now it may be years before the stupidity is rectified. This will only cause more illegal drug problems and/or suicide cases stemmed from people suffering needlessly.

    • i have been attacking the cdc on twitter on what i consider genocide an posting air bubbles for all junkies. i will get called on it but i really feel i am right.shameing has never hurt any one,others should do the same embarresment goes along way!!

  • I injured my spine at work in 1999 and now i fell and fractured my hip. The doctors have me on the lowest dosage i have been on in twenty years and my pain is killing me. Wallgreens pharmacy refused to cash my prescription saying that my three thirty milligrams a day is too much ? Since these guidelines have come out i lost over forty pounds in a year not being able to get my medicines. I have never been an addict and i will never be one but this terrible treatment i have been receiving is killing me. How much pain can a person stand ?

  • I too am left to suffer. I just got off the phone with another pain management doctor office, and somehow I know they are too going to accuse me of not needing opiates. I have nerve clumping which is so painful but I again will get no empathy. I do wonder if we should all stage our own “Jim Jones out” to get any attention to how we are forced to suffer. The only other group ever treated badly for being sick were AIDS patients, yet they were treated with whatever was available we are not. We are the “lepers” of 2019.

    • We are just a smaller part of the voting public. Most people don’t know what its like to go through severe pain. I’m sure alot will eventually. So sad, but a sign of the times and shows true human nature.

  • Why doesn’t the CDC send out stern notices that are hurting the Chronic pain patient like myself who has been on opiods for 20 years for pain. Now I lay in bed most of my life at 61 years old when just 4 years ago when taking the appropreiate dosage let me do everything. I was happy and able to live a semi normal life. Now I feel my life is coming to an end. I never in my life abused opiods and was always on contracts and never violated them. Now my doctor has taken me so far down in dosage I can know longer function very well. We need your help. I am considering leaving the U. S. to find better health care as the disabled are no longer wanted her. Thank you!!!!

    • Its all crazy. Sen. Gillibrand here in ny is trying to get legislation thru to try to limit prescriptions even more. Along with trumps people and all the others pursuing this very bad and wrong course…Crazy. All they would have to do is look at a pain patient like you or the rest of us and they would see…we are not abusive addicts! Years of taking the same doses without a problem…having some quality of life…Its really cruel and insane what they are all doing to harm us.

  • Absolutely right, ladies! These ‘kids’, are the ones for the most part abusing opioids illegally because they can not go to the doctors and get pain meds legally. They steal them from friends, relatives and do robberies or whatever they have to, to get their highs. Has nothing to with pain management. The government people know all this very well to, and that they were not going to be able to stop it. Unfortunately for us, somebody had to be the sacrificial lamb and put their heads on the chopping block…and that would be us! But they gotta know that we pain patients are NOT going to just lay down and take their crap without a fight, anymore!

  • As a Chronic Pain Patient being denied or tapered down on my medications, it is not right to be Denied medication that helps get me out of bed where I can semi function. It is putting patients in an Impossible situation. We take our medications as prescribed, submit to drug screens, and have never been busted for drugs. Most of these kids that have overdosed were not prescribed the medication. They either steal them or buy off the streets. Then they either crush them and inject into their arm or snort them and mix with other street drugs That is why they are dying. Chronic Pain Patients are being made to Suffer because of this Opiod Crisis. Please Do Not continue to deny our medications. We Deserve some Quality of Life.Every week their arepeople committing suicide because they are being denied their medications and they Cant handle the Pain!

    • To Darla;,I specifically wrote the cdc to ask for all the data they had on any persons whom have o.d.’s via their opiate MEDICINE taken exactly as their doctor had prescribed them…….NOT 1,,,NOT 1 SHRED OF DATA ON A SINGLE DEATH,,,FROM THOSE OF US WHO TAKE A LAWFUL MEDICINE AS PRESCRIBED BY A LAWFUL DOCTOR,,,The cdc exact words were,”’we have absolutely no data on any o.d.’s from patients who take the opiates as prescribed’,,from a lawful doctor,”Soo even the cdc admits,,no-one o.d. when they take their meds as prescribes,,,yet,,we have false data,propaganda from senators etc,,stating the complete opposite for political motives,,,,wth,,,,???when isn’t this fact exposed??maryw

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