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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  • hurt in 1988 RSD treated for 30 yrs. abandoned by drs in 2015 2018 COULD NOT GET A DR TOLD I AM POLITICL NIGHT MARE. STROKE AT 62YRS ONLY 1 QUARTER OF HEART LEFT. NO TREATMENT AT ALL/WE ARE NOT THE PROBLEM.IF YOU DONT THINK YOUR BLOOD PRESSER COULD RISE TO 315 BECAUSE OF PAIN

    • Blood pressure check at every pain Dr appointment , always well over 200/100 does not seem to matter ,not even mentioned, just another dosage drop ,

    • Thomas, the same thing happens to me at every pain mgt. appt. from the doctor who claims to care about my health but doesn’t comment on the increased B/P since the drop in dosage. They don’t give a damn, they do just enough to keep from being sued. We need to file a class action suit against the physicians who recommended these ridiculous guidelines without taking into consideration their impact on chronic pain patients. There is no one-size-fits-all dosage when it comes to patients for any medications but they’re trying to squeeze us all into the same little box!

  • I have to have pain medication just to function normally and have to go to a pain clinic that is slowly weaning me off of my medication, im scared! I don’t think that I can function with out these meds. M.S and Broken Back with fusion surgery that did not work.

  • This all needs to be stated LOUD n NOW before more pain patience decide suicide is the only way out of pain. The government as well as many other agencies MUST stop playing Doctor n leave the medical decisions to the Doctors who spent years becoming educated n have taken n oath to care for n manage the health plans including preventing unnessary pains, etc. of the patience that put their life n trust in. This article should be discussed on the News Channels n the shows like 60 min. Etc where they are poo pooing pain medication segments hurting legit pain patience further. Have a segment air how important it is to NOT denie humans with legit issues the right to be under a doctors care with the pain medication they need to have any sort of a normal life style rather then be bed ridden, turn to street drugs, or consider suicide. HELP is needed NOW, NOT a year from now. Praying for the people who can make a difference to STEP UP n save lives.

  • The problem with it .it’s that people who really needs it .takes the medicine as describe. The junkies are the ones that are dying cause they sniff up the nose or inject it .. period

  • A bunch of b.s. First the the Gov ok’s these big pharma to get people hooked or help pain pt’s. Now it’s the reverse an pain pt’s are the bad guy!! An the physician is to prescribing these valuable meds to pts who show up every 3 months an piss in a cup an do what their suppose to. Ethically, its wrong to be prescribing then stop an not taper or offer rehab an a replacement of the meds. Also, the pharmacists need to back off. They r not God!! Allthese od’s an crap prib involve illegally obtaining the meds, combining meds, or non-compliant pt’s. Yeah there are crooked Dr’s an pt’s, but hell look at our Gov ! Full of them! Crooked. Big pharma whispering in their ears. Regular rule abiding pt’s should not be paying the price for druggies an crooked Dr’s. .

    • Yeh, I mean, who are these people? Cdc, fda, government people who have so much power over the life and struggles of indefensible pain patients?? Its garbage. They think its gonna help to get things in order? Its like sending someone to jail for a petty offense and then come out alot worse than when they went in! Not gonna help anything by abusing the wrong people, pain patients, that is.

  • Wonderful article clarifying the intent of the CDC Guidelines. As a person with non- cancer chronic pain pain, I can relate to much of what was described from the perspective of the patient. Thank you for a well written and objective article.

  • I have been a chronic pain suffer due to nerve damage for 20 years. I’ve never doctor shopped or abused my medicines. At my last doctors appointment, my pain medicine was slashed 1/3 less. I had been on the same dosage for almost the last decade. Now instead of sleeping, I’m up. Because I’m so tired my pain has increased two fold, it’s honestly more than I can bear.

    • This whole opiate debacle has zero to do with pain management patients and doctors. The DEA want to play doctor without the years and sacrifices that of med school and a practice. They are, along with all the other alphabet government agencies allow all these illegal opiates to cross into the USA as it is big business$$$ to them. Their budgets get inflated and who knows what kinda drug running they do to generate black money.
      If they want to screw over legit pain patients and doctors by reducing their meds and chasing pain docs out of business, then they better be ready to fill a lot of body bags.

    • I am in the same boat and really at a loss. What all of a sudden now it’s a problem…It’s like they have your life in there hands and they are so afraid of losing there licenses that they do not want to fight for there patients. You would think that they would want to fight to keep there patients…But I guess not. I was in the pharmacy and about 25 feet from the counter and the pharmacist decides that she wants to have a conversation about how she has the power not to fill it. The one thing that sticks in my head is the gentleman that I have never met came over to me to tell me I really need to get off the medication that I am on. Where is his plaque? It is really just messed up. Some people really need the Medications that they are on and should not have to deal with want to be Dr’s. The pharmacist should not have put my business in the street anyway.

    • It has been 16 years that I’ve been prescribed strong pain meds. after someone on their mobile device rear ended me. breaking the seat back on my Aerostar van. I fought the pain but eventually it won, my back has just gotten worse.I had worked for my father Ziebart rustproofing since freshman in High school ,along the way we also started another business of sandblasting and car restoration. I also had been a Captain on our vol. fire dept. 26 years. That was hard to give up, Not good to live with this much pain lower L345 Sciatic also Thorasic . I had a Dr. do testing because laying on my back to sleep my hands go tingly he wanted to do carpel tunnel surgery, which wasn’t why that was happening. I didn’t have the surgery but the wheels were spinning and was charged for it anyway. I didn’t have to pay for the surgery that wasn’t done altho I had to pay the about 1500$ for the test that was done. I thought the test was for my spine not my arms easy money for the Doc. maybe? I have had spinal injections . The Dr. hit the nerve on 3 different times of 11 injections NO MORE INJECTIONS. Any way after switching between providers hoping for help I went back to my family Dr. who is a TV, public radio host he walked out on my first time back to him because of the high dosage of pain meds. He prescribed them to me to start with prior. The CDC or Government has the doctors so fearful. HE TOLD ME HE COULD LOOSE HIS LICENSE and walked out of the exam room. He had been my main doctor for about 30 years even delivered my 2 children and has taken care of them till adulthood! I am now recieving pain meds from pain manegment department of prior Doctors group. feel free to contact me madcitysandman@hotmail.com

  • Couldn’t agree more Carla. That was quite a rant and I totally get it. If you look back in the comments history, you’ll see I’ve commented several times. I’ve lent some ideas, advice and support on this sad n frustrating topic. I think one of our biggest problems is we are the only ones speaking out, which isn’t much help given the fact that they will just label us as “drug seekers” what we need are a few high profile people with the guts to speak up for chronic pain patients. Like someone with celebrity status, someone who can reach the masses. There are various efforts underway that I’m aware of ie…. Don’t punish pain rally.com, which hosts protest rallies across the country a few times a year and also has a Go Fund Me campaign to raise funding for TV commercial time to educate the public. There is also Robert Rose with his “operation Starburst “ he is a retired USMC veteran who is suing the VA and several states for the “unconstitutionality “ of the CDC “voluntary “ guidelines for prescribing opioid medications. You can find out all about his efforts on YouTube. He provides information on how to join the existing complaints an or how to file a new one if your particular state has not had someone file as of yet, do check it out. I’m sure there are other movements I’m unaware of as of yet. I think there are enough people angry about this government overreach, it just needs to be better organized, so that we’re all coming together. Remember, we’re going up against the most powerful organization in the world….the U.S government. And by the way…. you were so right about the prohibition bit, they created an entire criminal enterprise with that stupid stunt. And now they gave up on marijuana, no more “it’s a gateway drug” all of a sudden, it’s fine, here….have some weed, but you have to give up the medication that’s helped you survive and function for years….WHAT A JOKE!

  • I have had 4 knee surgery and not have arthritis in both knees was in a car accident and have 3 hernerated disk in my back I been see pain management for 20 years and was told sorry can’t help you have a good like and go to rehab I don’t take pain meds cause I wasn’t to I take cause I need to and now all I do is cry cause the pain is 2 bad to stand.

    • Patty I can relate I too have been on meds for long term until now.at first volunteering taper till the point of endless suffering under protest of how bad I feel. I can only wish for a miracle or I don’t think I can go on, endless sleepless nights days of laying in bed due to pain Flair’s. Constant battle to find a reason to go on.

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