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 (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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  • @Richard A. Lawhern PhD please disclose your association with and payments or perqusits that you receive from all of the various pharmacutical associations, pain management prescriber associations, opioid manufacturing corporations and pharmacutical distributors. Your work seems diligent but your selection of facts and especially your interperation of the data is an intellectual avalanche of criticism against any opinion in that points out the culpuability and crimality of the Big Pharma industry and the pharma distribution industry.

    • John Moir, despite your apparently intended insult, I will respond with courtesy to your question. I am not now and have never been paid by any company or agency of pharmaceutical companies or physicians. I receive no honoraria or compensation for the work I do on behalf of pain patients.

      Starting in 1996 I became a volunteer webmaster, support group moderator, and research analyst for people in pain. My wife and later our daughter became chronic pain patients; at first in their behalf, and later that of other patients, I researched what was known of face pain of neurological origins and later expanded my scope to address public policy on regulation of opioid analgesics. My volunteer work for the US Trigeminal Neuralgia Association was acknowledged in an Aesculapius Award for Excellence in web-based health care communications, in 2001 – the first of several awards made to TNA.

      I do not advocate for the pharmaceutical industry. I merely insist that criticism of that industry be based on something beyond scapegoating and unsupported or biased opinion. As I have written elsewhere, there is adequate evidence of corporate misbehavior on the part of companies who carelessly marketed opioids as risk-free, neglecting the reality that for a small minority of people in pain (generally on the order of 1-5%, depending on the source you pick), short term exposure can create dependency or promote any existing predisposition toward addiction. However, data published by CDC demonstrate beyond any reasonable contradiction, that despite the carelessness or profit motive of corporate players, our US opioid “crisis” wasn’t created by prescriptions – not even those diverted by theft or corporate negligence by drug distributors. The core of the addiction crisis is alcohol and street drugs in populations being marginalized by economics and automation of jobs formerly done by manual labor. The “war on drugs” is a miserable policy failure for people with addiction, and a practical disaster for people now being denied treatment for pain.

      I’m not hard to find in a google search or a visit to Facebook or Twitter. My 27 year record of online and print publications is extensive and transparent to public scrutiny. In a spirit of fairness, I suggest that you clarify your own record and associations, John. Who pays you for your attempts to discredit advocates for people in pain, and why?

    • @Joseph,,,i can attest to the FACT,,,,MR.LAWHERN ,,,,NEVER EVER,EVER,,RECIEVED ANY $$$$$$$ FROM ANYONE,,,,,,,like many of us who advocate,,I know thats hard for people who have corruption in their hearts,OR THEE ,”ADDICTION OPIATEPHOBIA /THOSE WHO THINK THEY HAVE THE RIGHT TO TORTURE OTHER HUMANS SIDE OF THIS,,,,but all of the advocates I know ,who advocate for access to humane effective care to all in physical pain,with the use of thee MEDICINE opiates at effective dosages,,,WE TAKE NOTHING,,NOT 1 DROP,,,OF MONEY FROM ANYONE,,,maryw

  • John Moir and Joseph, you are both factually wrong and CDC Wonder database data prove this reality. Neither AMA nor the pharmaceutical industry “created” the opioid “crisis”. The idea that our public health problem – which has always been dominated by illegal drugs, not medically managed prescriptions — is an outgrowth of over-prescribing is silly nonsense! It’s an urban myth greatly magnified by the CDC as a consequence of misinterpreting or distorting the implications of their own data.

    See for instance “The Phony War Against Opioids – Some Inconvenient Truths” in the June 21 2018 issue of *The Crime Report”. Alternately “Are Prescription Opioids Driving the Opioid Crisis? Assumptions vs Facts ” *Pain Medicine* Volume 19, Issue 4, 1 April 2018, Pages 793–807, https://doi.org/10.1093/pm/pnx048.

    The US public health crisis with opioids is driven by multiple socio-economic factors surrounding the hollowing out of American rural communities in the Rust Belt, deep South and West. It is largely a crisis of hopelessness, not medical exposure.

    The demographics of addiction are vastly different from the demographics of chronic pain. Initiating addicts are dominated by young males, many with depression and other mental health issues. Chronic pain is typified by women of middle age and older. It a woman’s life is stable enough to allow her to see a doctor repeatedly for pain, she will almost never be found to be a substance abuser.

    Kids now have rates of opioid-related mortality six times higher than seniors – but senior overdose-related mortality is the lowest of any age group and has been stable for the past 17 years. Inconveniently, opioid pain killer prescription rates to seniors are several times higher than to kids. Thus the group which has benefitt4d most from liberalized prescription policy before 2010 has shown no elevation of mortality due to drugs. NONE.

    The demographics of an allegedly prescription-driven crisis don’t work now and never have worked. Our government’s war on drugs has turned a real public health problem into a dual crisis of under-treatment and patient desertion by doctors fearful of being persecuted by DEA and State authorities. The AMA didn’t make this mess. Government agencies did, while searching for simple one-dimensional solutions to a complex multi-dimensional problem.

    Fair disclosure: I am trained as a data analyst and systems engineer, not a medical doctor. However I have published over 60 articles and papers, some of them co-authored with medical professionals and others in authoritative medical journals.

  • The opiate crisis was created by the AMA and the pharmaceutical industry NOT the CDC. So sick of NADAC placing blame where is does not belong.

  • As the Holiday is near, we need to take this moment to look at different perspectives to treat pain.

    First lines to opioids:

    1. Acupuncture
    2. Cold/hot pads/ Chiro
    3. Exercise/PT
    4. Massage
    5.Meditations/counseling
    6. OCD
    6. Opioids

    Happy Holiday to you all

    • Thank u 2 the doctors who have written in, my pain specialist of 8 yrs would never. I understand u r suggestions & MDs should use these suggestions as first course of action b 4 opioids. As someone who worked out 6-7 days a week for yrs b 4 I got so sick, a lot of those suggestions were part of my course of action, now being basically in bed most days , only leave the house 4 md appointments which is not easy, I can not have any injections due 2 aderal failure from prednisone, & can not b approved 4 any surgery now, being cut down on opioids has declined my little quality of life at home. My md knows this is wrong but if it comes to my quality of life or the govt possibly investigating him/ his quality of life, I am the one who has to suffer. I realize u r suggestions r good but 4 those of us who tried them or unable to afford or unable 2 do them it’s frustrating cause what was working to control our pain is taken away unfairly & I think aggresstion is being taken out on u. Thank u 4 writting in , more MDs should. The MDs who had pain plans in place r now running from them & not standing behind their patients. If MDs banned with their patients we would not b in this position.

    • T. Trust!
      It looks is if you are continuing to market your misinformed, deceptive and unscrupulous nonsense on here. Most people with long term intractable chronic pain have already tried everything on your list. what your are doing is repeating the marketing from various new age, quacks, charlatans and people who saw a way to profit from the pain and despair of others.
      All of this nonsense was peddled along with the lies, deception, and fear based marketing opportunities created by an unregulated industry.

      Science tells us that most of this stuff is deceptive, if not plain useless or dangerous. Clearly you have a financial or ideological point to sharing your willfully ignorant, nastiness, in this forum.

    • T. Trust,
      The most glaring thing is how you define pain, the same way all of the other quacks and charlatans try to re-frame it. First off, the need for a product or services, as if there is something you can buy to fix it.
      You don’t make any distinction between occasional pain from overdoing an activity, pain is your body telling you there is something wrong, to stop an activity and rest. It is very different from having a genetic disorder, an injury or damage to the nervous system. This is the same kind of deceptive logical fallacy they all use to market fake studies, and mislead the public about pain.
      To lie to market a product is immoral, and repeating nonsense you read online as if it is factual is a lie.

      Acupuncture does not work for Intractable Chronic Pain, nor do the other remedies you listed. They are all marketing gimmicks and lies. Most occasional pain can be treated with rest or a hot or cold compress, that does not mean that it will work for all kinds of pain.

      Clearly you do not know what you are talking about1

    • Johnson,
      You’re always commenting on things not to do, but never on what to do.

      How to solve, not just have an opinion.

    • T Trust, I commend a reading of the lead op-ed in *Practical Pain Management* for October 2018, as a perspective on “alternatives” to opioids. Title is “Behind the AHRQ Report – Understanding the limitations of “non-pharmacological, non-invasive” therapies for chronic pain”. I co-authored that article with Stephen E Nadeau, MD — a senior physician with over 100 peer reviewed articles in medical journals. What we show is that each of the alternatives you have named has a role to play as adjuncts (additions) to treatment with analgesics or anti-inflammatory drugs. But none has been trialed as replacements to such measures, and none appear to have major long term benefit even as additions to usual therapy. The state of precision in medical literature for alternatives to opioids is truly abysmal. We literally don’t know with any consistency if the alternatives work any better than placebo — yet their advocates and proponents claim such measures should replace access to opioids. This over-hyping of experimental and unproven therapies is not helpful or evidence-based. At worst, it can represent medical quackery for profit.

  • Good day all, just a few suggestions to those of you who feel hopeless due to “our opioid crisis” First: no matter how futile it may seem, keep fighting! Send letters and/or emails to your elected officials. You may not get the response you had hoped for, but they need to hear from us, the more the better. I have reached out, and received surprisingly swift responses. If you are mistreated by a pharmacist, don’t tolerate it. Remember, you are still a customer, and most likely are are on other medications as well. Make it clear that you expect them to fill ALL of your prescriptions or you will find a pharmacy that will. You can also reach out to management or contact the corporation when it involves a large chain pharmacy. Keep in mind, the pharmacy business is very competitive. We have rights as patients, consumers and human beings for god’s sake. Don’t be ashamed if you take opioids, or are in need of them and have been cut off. Make your differing opinion clear when the subject comes up. I have surprised and enlightened several people about the CPP community and the things that are happening, which most people are unaware of. Lastly, and perhaps most importantly. If you have a physician who decides they are going to cut you off, especially after treating you long term with opioid medications, make it clear that it’s unacceptable, and if your pleas fall on deaf ears, find yourself another doctor. Even if the new doctor refuses to treat with opioids, at least the message to physicians will be clear. You will treat ALL of me, or NONE of me. Go to the CDC website, print out the opioid prescribing “guidelines” and show it to them. Nowhere in the guideline does it stste that opioids should be discontinued or abandoned. If a physician cuts you off immediately without justification, report them every agency that exists and seek legal advice as to filing a malpractice lawsuit, as this would be a clear case of medical malpractice. And please, for god’s sake, don’t allow someone to force a procedure or device on you that you’re not comfortable with. Their are many coming out of the shadows to profit from our current crisis. It’s your body, your health, your life and your choice, good luck.

  • Joseph, didn’t make it past the first paragraph and the sensationalism is already apparent. They are incorrect, obesity is number one and smoking kills a half million people annually, alcohol estimates are at 88,000, what epidemic. Difference is….they tax the heck out of that stuff and make billions so it’s untouchable….fake news. And lay off the Sci-Fi channel dude.

  • I wish everything you say was actually happening I just get only availability of a Doctor and nothing else. I when younger when to a chiropractor who sent me into the air from his table he hit my nerve in the back and called for days he knew he did wrong. I still to this day have problems. I have a disease that they say they can do other things but that is a joke. No help because I can’t afford the doctors that know my disease so go on and suffer as the doctor before my doctor now she said I had no insurance would give me no meds and told me to suffer hospital also. is this fair no it isn’t. Insurance say one thing and do another why cheaper that way so now I fight what choice do people have Its not you so you have no choice but to fight for you nobody does it for you. my sympathy to all that are suffering my hope and everything else that on day this madness will stop. We must support one another not scream that you are not good enough love stop the hate. I trust my opioid because it worked not because of highs ok. do I get what I need no I will suffer because of lies and we all know it. please take care because you are a very special person. not a druggie.

  • Thanks, I believe we share some common ground. I don’t think they should be a first option by any means, but another tool in a physicians toolbox. I’m certain many doctors would like the ability to choose, while being mindful of the need to proceed with caution.

  • T. Trust, it’s obvious that you are not in favor of opioid use, that has become quite clear, and you are entitled to your opinion. However, don’t start throwing around the “new” study of the week to bolster your opinion. Remember, for every study or article you quote, there are two saying the opposite, as is true for most things. Better yet, read all these comments, comments from actual patients, not talking heads trying to push their agenda. The opioid prescribing increased for two reasons: #1) there was a recognition that pain was being under treated and needed to be addressed, it’s in the patients bill of rights, and in several acts passed by congress #2) The baby boomers are reaching the age group when many of the painful conditions start to add up and can no longer be ignored. Much pain cannot be seen by others and therefore is always looked at with skepticism. There are also many, whom because of the negative stigma, caused by sheer ignorance, would rather forgo relief, in a false sense that they are stronger and morally superior to those who choose to utilize the opioid option. I for one can tell you that opiod medications have allowed me to continue working and be a contributing member of society. Yes, there are other modalities, such as injections, chiropractic, NSAIDS etc., and I also, at times, when appropriate use these methods as well. Nothing takes all the pain away, nor do I expect that. It’s not a black or white issue. I suggest CPP use everything in the arsenal that their body can tolerate to fight their daily pain. Please let’s not demonize people for seeking a better quality of life.

    • Lance,

      I agree with you.

      I consider opioid to be one of the best medication for critical care. However, other procedures should be acted on before proceeding to opioid.

      By the way, well written comments Lance.

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