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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  • I’m not even going to list my diagnoses and allergies–the pain in my hands is too severe–and I could be any one of the other commenters anyway. I’ve been researching these “guidelines” since my pharmacist informed me last month that she will no longer honor my prescriptions. Very impressed with this piece and hopeful that more people like the authors begin to fight for those of us who can’t. What I don’t understand is how the CDC can’t–or won’t–see the enormous issues they are causing. I believe we’re going to see a rise in heroin use, illicit opioid abuse without a doctor’s guidance, and suicide. When you wake up every day because you can no longer sleep through the pain, when you hurt so badly and so *constantly* that it affects every single aspect of your life, what options do you have if you’re abruptly cut off from meds you are *dependent* upon? Even if you’re able to taper off, you are looking ahead at an extremely painful and dismal future. I don’t want anyone to hurt like I do, but sometimes I think that’s what it would take to understand what they are doing to people who just want to be ok. Not even good. Definitely not great. Chronic pain patients know. We just want the pain to be tolerable.

  • I have 6 herniated discs, degenerative disc disease, spinal stenosis, degenerative joint disease..both knees, hips, ankles, are bone on bone articulation. Additionally, I have fibromyalgia. I also have venous stasis ulcers on my abdomen creating constant pain. My meds have been cut completely in half and I’m told I’m lucky to have what I have. Every day of my life is agony. The first thought/sensation I have upon waking is unrelenting pain. Marijuana is now legal, heroin addicts can go into tents and get clean needles and medical supervision, but I am denied proper pain relief, and I am treated like a criminal to get the meds I do get. Pretty screwed up if you ask me.

  • 2006 we were slammed in the side of our car by f250 pu truck knees shattered hipbroken disc bulge at c t and l spine. This was truck drivers fault he was drunk.he spent 1 day in jail an license suspended for 1 year. We got life in pain. We were both on oxycodone 30mg 4 times a day.just got cut 3 oxy 10mg. A day. There are 4 liquor stores within 5 miles of my home not to mention gas and grocery stores selling alcohol.2016 alcohol deaths 88k.2016drug deaths 60k. Includes illegal heroin and imports from China.oh and by the way over 400k died from cigarets.I can’t get my pain pills so how bout a carton of smokes and a case of vodka.cheers people, this so wrong. Start writing cdc/ama/congressmen better yet ACLU. Oh I forgot new pain doc said join the ymca go swimming that may help.

  • I have m. S. And DDD and spinal stenosis and COPD. Arthritis in my spine. Pain throughout my body. Without my meds I can’t walk , cook get dressed. They gave me life back. Now they are taking my life away without giving me what I’ve been on. I have tried everything before being put on these meds. I lost everything before becoming disabled. Finally I got it back. Meds did this. They gave me another chance to be alive.

  • I am a chronic pain patient I just moved to Gorgia and got new doctors. I was on methadone when I moved here. I was in pain management for over 10 years. The family physician would not fill even tho I brought in all my bottles. Pain management turned me away. Won’t even see me. They don’t prescribe methadone I asked both doctors to switch it or give me suboxon so I don’t go through withdrawals and get sick. Nobody will help me. My family doctor prescribes but not to me. Idk what to do. I understand the scuicide delimma I mean nobody wants to die. But to live in this pain and doctors not willing to help. He said I don’t know you. I was in his office for 3 hours in a office so small. I asked couldn’t you call my doctor. He said no. He didn’t even get me to sign releases for medical files nothing. Please help me.

    • So its been a bitsince my last post. As time goes on and i get sicker..now unable to barely walk as my legs and feet are in so much pain. I spent my last bit of money which was 75$ for a cream . ive tried cbd cream. I am on blood thinner so cant tale nsaids aspirin ect. Cant smoke pot cause makes me paranoid and sickly. To not care about myself or push everyone out of my life..i am afraid time is running out. No help from anyone i even emailed the local news channels. I guess i have to actually kill myself or attempt to for tgem to help or it even make the news. For the people my ass. Cant sleep cant barely drive and i am everyones ride..if they cant get to work i have no money to pay my bills..i know it would be easier if i wasnt here but i should not ha e to feel this way..i pray there is a changesoon. How many of us have to die?? Or live a life like weare dead. We want to do this tge right way yet we are forced to find other ways..heroin isnt theway yet i know many who havewent that way or the methadone clinic for relief..they will gi e you 200 mg or more if you want it. No pain bit i shouldnt have to go that route either. Screw you FDA and screw you the doctors who took a oath and dont help. Screw you donald trumph for allowing u s to suffer because of addicts. Im appalled. We are all born to die wby does it matter how. If somone wants to over do it its thier right. I jist want to have a normal life where i can walk and enjoy family gatherings. Praying for all of us..if there is a god he needs to help us now..

  • My doctor will not help me with appropriate dose.I’m not ok…I quit my daily life getting a new dog. He thinks it’s ok I quit my daily walking..I have severe sciatica?…he missed my broke neck in 1997….plus huge fall in 2006..now I went off them to show this doctor I could…he wants to stop me and refuses to allow me back to my old dose of 3×30 mg per day to 15 mg that only work at 30…I don’t abuse these I am in untolerated pain and the surgery I need to have makes me feel that is the end of me and discouraged as he doesn’t want me like that for a patient…I never asked for unreasonable. 30mg worked thru the second injury…I endured broken neck pain till I went to a pain clinic no longer able to deal with severe pain 5 years later…severed nerve in ulner side right hand.ty

  • What these doctors and the government are doing is horrible. My doctor would not listen to me at all when I tried to present him with new evidence and information so just let the CDC now says it never meant to harm the treatment of chronic pain patients with its standards.I have very severe ailments and was taking a high dose of morphine. For quite a while. The doctor was convinced that I should cut back to 90 mg.2 months or so ago he Cut back 1/3 of my medication to 120 mg. This is after much production previously. He thought that I would be able to get my insurance company to cover the 120 mg. But they have not been willing to do so. At least not in the form he prescribes, 60 mg (2 30 mg pills) 2x a day.
    They will pay for two 60 mg pills a day but I don’t think he will want to Prescribe it this way because he told me that I would still have to cut down to 90 mg. The pain doctor I saw wanted me to stop taking it altogether.She even wants me to start taking the morphine agonist which she claims will help me. I’m afraid that it will mean that if I go to the emergency room After an accident I will have no chance of being given pain medicine that would help me. If they gave it to me it wouldn’t help me. I am not going to do this. You know if it would really help me I would do it but I honestly don’t believe it. I think it’s all part of the hype surrounding the opioid hysteria issues. Yes there is a problem about opiate overdose. But if it comes from Street fentanyl and other drugs not from prescriptions. For God sake it’s different to be a chronic pain patient then it is to be a junkie. And even my doctor says he doesn’t think I am an addict, I’m just Tolerant of opiates because of how long I’ve taken them. This seems to mean that my opinion means nothing. I know that he is pressured by his hospital and other agencies and told me that he was terrified that he would be put in jail or have his license away or get in trouble. That’s one reason why I agreed when he took away the third –without complaining.I’ve been in much more pain since then. I cannot drive around as easily, doing the things that I need to do.
    My husband says he just simply doesn’t want to consider the CDC’s change of mind or what I am thinking. But I’m going to fight it to the very end. The problem is of course that he will retire and then some other doctor might not prescribe it at all. So I may have no choice. This is a really bad way to treat all sick patients with very many painful ailments. The government deserves a deep purge for this reason and the doctors deserve to have to experience what we have experienced. Are we human beings or are we not? Are we patients or are we not?

    • I live in Suffolk NY it’s so bad in 2011 Dec 17th when I went to my Dr. he told me “I can’t write you anything anymore period”I said dude it’s a week from Christmas who am I gonna see?I was unlucky enough to have gotten hurt and saw PMR the same week Purdue drug reps started bum rushing PMR’s(95-96) and the day I had my appointment they were there. My Dr gave me 2 pamphlets,one saying it was nonaddictive and wrote me what I called Blue Whales..160 Mg of Oxycontin every 12 hours with liquid Oxyfast for breakthrough pain.were do you go from there?I was 22 in college?

  • What these doctors and the government are doing is horrible. My doctor would not listen to me at all when I tried to present him with new evidence and information so just let the CDC now says it never meant to harm the treatment of chronic pain patients with its standards.I have very severe ailments and was taking a high dose of morphine. For quite a while. The doctor was convinced that I should cut back to 90 mg.2 months or so ago he Cut back 1/3 of my medication to 120 mg. This is after much production previously. He thought that I would be able to get my insurance company to cover the 120 mg. But they have not been willing to do so. At least not in the form he prescribes, 60 mg (2 30 mg pills) 2x a day.
    They will pay for two 60 mg pills a day but I don’t think he will want to Prescribe it this way because he told me that I would still have to cut down to 90 mg. The pain doctor I saw wanted me to stop taking it altogether.She even wants me to start taking the morphine agonist which she claims will help me. I’m afraid that it will mean that if I go to the emergency room After an accident I will have no chance of being given pain medicine that would help me. If they gave it to me it wouldn’t help me. I am not going to do this. You know if it would really help me I would do it but I honestly don’t believe it. I think it’s all part of the hype surrounding the opioid hysteria issues. Yes there is a problem about opiate overdose. But if it comes from Street fentanyl and other drugs not from prescriptions. For God sake it’s different to be a chronic pain patient then it is to be a junkie. And even my doctor says he doesn’t think I am an addict, I’m just Tolerant of opiates because of how long I’ve taken them. This seems to mean that my opinion means nothing. I know that he is pressured by his hospital and other agencies and told me that he was terrified that he would be put in jail or have his license away or get in trouble. That’s one reason why I agreed when he took away the third –without complaining.I’ve been in much more pain since then. I cannot drive around as easily, doing the things that I need to do.
    My husband says he just simply doesn’t want to consider the CDC’s change of mind or what I am thinking. But I’m going to fight it to the very end. The problem is of course that he will retire and then some other doctor might not prescribe it at all. So I may have no choice. This is a really bad way to treat all sick patients with very many painful ailments. The government deserves a deep purge for this reason and the doctors deserve to have to experience what we have experienced.

  • Yeah I’m at 450 mg. I’m on a 75 mcg fentanyl patch and oxycodone every 4 hours. Been on it for at least five years. Now they are weining me off down to 90 mg a day. I cant take acetamenaphin because of my liver and cant take aleve or advil or steroids because I have water retention big time. This will make me bed ridden when it’s all said and done. It’s not fair. I’m going to feeling I can get around but still painful to not doing anything. What a life.

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