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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  • last yr i called my pcp to refill clozaphan 0.5 mil 2xa day for anxiety with s histor of znxiety and deo.ths dr acter 38 yrs as bindenec me not even giving me my hivh blood medicine.landedbat er wuoth dxtremy high bloof predsurd
    i aleays respted my med and whst he did wad totsl iresponsible on his pt.

  • Ive also experienced this. Dropped after 16 years as a intrathecal pain pum patient! My dr wont even call back! Amazing really!

  • 20 years ago I began my pain control journey after car accident n multiple surgeries. After many years struggling my intrathecal pump n low dose Norco was making life bearable. Out of nowhere others started appearing to mark my medical chart. Then after a lil run around I was told I had to do my ymth urine test. Never had to. They insisted I knew n would test. Because Im honest w my doc, I tested. In the past, when testing for preop, Id been thanked for not doing other drugs. This time I was dropped for wanting to be better than bearable..I want to feel alive, smoking mmj which is legal n Id been doing for years. Just dropped like my dr didnt know me after 8 years! They said pain management was next! Im a pm patient!4 times a year I get my intrathecal pain pump filled. At my fill appt my reg dr was replaced. I sent him a message through s nurse Ive known for yesrs. 3 weeks and no contact. Ive been ditched by my pain team of over 1y years! Just ditched. Amazing. 1 doctor did say I wasnt the problem as still under 900 w/ mmj and norco but still couldnt help because they would just throw statistics at him if he tried to defend! NOW WHAT? Kaiser!

  • I am a chronic pain patient and I lived in Vegas for five years getting them with no problem, I move back to Michigan and I can’t get any help even though the doctors here have my records, x-rays and everything else.One doctor even tried to change my blood pressure medicines. I hate the pain clinic because Im scared of needles. I am depressed and hurt so bad some days I can’t walk or function.

  • If you have not participated in the opportunity to share you story and you want to – as a patient, a care partner, or a clinical helper – please take the opportunity to do so here at this link. One patient story is an anecdote. Ten thousand patient stories are data that we can analyse for evidence of trends, harms, improperly functioning policies. Clinicians and patients have to get on the same team. Please join your voices to this nationwide chorus.

    https://www.surveymonkey.com/r/Y8YXRJ9

  • My take is that there are still high numbers of opioid deaths could be due to a significant number of chronic pain patients who, obvious enough to me but not to my own medical team, also struggle with depression for the loss of their quality of life and no other easy options for pain relief other than their prescription pain medication. So, when physicians, who have given an oath to “do no harm” decide they no longer want the scrutiny of the Feds for every pain control script they write decide to stigmatize their already fragile patients with urine screens and pill counts or outright deny their ability to prescribe opiate medication and cut them off, I know for a fact that there are depressed/chronic pain patients who take their own life, often with an overdose of the highly toxic meds they have left. I don’t know if those suicides get grouped in to the number of addict’s accidental overdose numbers, but I’m betting they do.

    I switched my HMO’s medical group after having bad experience after bad experience with my own doctor (who first prescribed the opiate meds for my chronic, misdiagnosed hip pain), her staff and the pain management clinic I was required to visit made my life miserable with these Fed-mandated hoops and extreme rudeness because, as my doctor explained even as her staff was horrific to me when I tried to get my monthly Norco refill, they just expect that too many are just addicts seeking drugs to use or sell. I had been to this doctor’s office for over a decade and they knew I was health nut who didn’t smoke, drink or ever use recreational drugs. So, I moved my care to a new IPA.

    When I saw my new primary care doctor to establish my care, I was almost out of my medication (it didn’ matter for scheduling where I was in my monthly script, they made me wait 3 weeks for the appointment). This doctor said, “I don’t write opiate scripts. You’ll have to get that from pain management.” This appointment was another month away as it needed a referral and the clinic’s schedule was booked. So, my new doctor wrote me a sub-clinical prescription for Tramadol, and a script for Cymbalta.

    Within 2 days, I was in agony and going through withdrawal from what had been a high dose of Norco. And the Cymbalta? He had written that for twice the highest recommended dose. Luckily, my pharmacist caught it and questioned the doctor before giving me the toxic regimen. I called the doctor to get an explanation, but he and his staff had gone to a conference and weren’t available. Another physician saw me 3 days after that and put me back on my Norco.

    It’s six months later now, and I’m now on my third primary care doctor because no one wants to give chronic pain patients the time of day. They don’t listen. I have a decent pain management doctor now, but I’ve experienced so many unnecessary delays waiting for pre-authorizations, denials for three different non-opiate pain therapies as “investigational,” and so many providers for psychological chronic pain treatment just don’t bother to return phone calls. I’ve contacted 10, so far and the only 2 who returned my inquiry didn’t treat chronic pain and weren’t taking new patients (websites say they did, but no one updates these sites).

    I currently have five open grievances and appeals against my health plan with the state’s advocate office for the delays, denials and general rudeness all related to the horrific quality of care as a chronic pain patient. I have some acquaintances and family who also suffer from chronic pain but arrogantly say they avoid these problems by refusing to take prescription pain meds. They shouldn’t have to do that but, if they had my level of intractable pain, they would not be able to say, as our former Attorney General Jeff Sessions admonished, to “just take two Motrin and buck-up” through the pain.

    I think if someone hasn’t experienced chronic pain, they have no idea of what hell it makes for the once active human being to have to suffer needlessly and then to reap the restrictions of a misunderstood “opiate crisis” upon them, as well.

  • I just today have received a call from a pharmacist at a big chain demanding that I reduce a patient’s Norco. He is receiving #240 a month. Has been receiving that amount for the 8-10 years I have known him. He remains mobile, functioning at home. The pharmacist is instituting their “protocol”. All this without patient consent. That pharmacist insists he is not practicing medicine. He is. He is instituting a reduction plan without patient consent, without evidence based medical practice, and against my written orders. The patient has no choice. If he goes elsewhere, the CURES database will show he is going to different pharmacies for narcotics, which is “suspicious” behavior. If I complain, the pharmacist can report me to the Medical Board for overprescribing and I potentially have the DEA raid my office, take my prescription pads, suspend my DEA license, and leave my patients in limbo for the months to years I have to defend myself and my license. Having the DEA suspend my prescribing AUTOMATICALLY suspends my hospital privileges, my California license, my ability to see Medicare and Medicaid patients in a series of dominoes.

    So don’t wonder why doctors practice in fear. The presumption here is guilty until proven innocent. All it takes is one complaint from ANY source, whether justified or out of retaliation, and your license is gone, your reputation destroyed.

    • Not sure what state you’re in, but you might take a look at how Dr. Sherif Zaafran, president of the Texas Medical Board, has been addressing this issue in Texas. The TMB has issued a public warning to pharmacies to stop doing exactly this.

  • I had been receiving 120mg of oxcycontin a day due to cancers-plural-and my Dr. was so afraid he cut me to 30mg.I will now have to go into Hospice care to get a dose strong enough to make me comfortable Hospice…just for pain relief. smh
    Something must be done to help us get relief, not eliminated, just comfortable.I took my radiation schedule and showed the Dr.His response, it is a law.It is NOT a law, only a guideline.My pharmacist asked me if I was cured and weaning down, I said no, Drs are afraid because of the dammmmmmm GUIDELINES and cancer is exempt from both law and guidelines.Am I supposed to buy a $10 bag of tainted heroun???
    Hospice here I come.😖😧😱

    • Just wanted to say that it is really heartbreaking to read all the real life stories like yours and realizing that, alot of this insanity of depriving suffering people of their pain meds., started with all those drug abusers who are using opiates for no other reason than to chase highs. They are blaming us for all that! Utter insanity and heartlessness.

  • Thank you for writing this article. I am one of those patients who takes opioids for long term pain and tho’ my Doctor has not had to reduce my pain meds, I know from discussions with her, she has felt the urgency of the gov’ts involvement regarding the issuing of opioids to her patients. I am very upset with the fact that addiction vs dependence due to long term usage has not been given more thought by those in the medical & pharmaceutical community. You would think they would understand the difference. Those of us who have never taken any kind of illegal drug in our lives, should not have to suffer because of those who choose to abuse illegal or ill-gotten prescription drugs.

    • I am also a chronic pain patient for the past 27 years. I suffer with complex pain and medical issues and my doctor has already told me that I have to see a pain doctor rather than my primary care doctor for pain medication. This creates not only a financial issue for me because I will now have to pay $45 to see this doctor, but it’s also a major inconvenience especially when you’re in pain. I’m appalled that the government and the CDC has not taken into account that there are people who might be dependent physically on their pain medication but not addicted mentally to the drug and are, in effect being punished!

  • These kinds of sensible fact based comments were shut out of the discussion. No pain physicians were consulted on these guidelines. The DEA threatened physicians who spoke up or that continued to treat their patients. Even after opiate prescribing dropped, they continued on this pogrom.
    They deliberately conflated addiction and dependence, because it was profitable. The rising deaths are an indicator that misleading the public and misreporting data are killing people, yet they continue.
    A lot of unscrupulous, greedy, and unprofessional corporations and media outlets were cheered on by industry interests at the FDA, into denouncing opiates. Credible news organization ran opinion pieces, and advertorials on the evils of addiction, focusing on pain patients and prescription drugs. The facts tell us that there was some over prescribing, but most of the opiates available before 2014 were illegally diverted from the supply chain.

    Fentanyl is a lot cheaper for illegal drug dealers, and it is now being added to other drugs like Meth, or fake anti anxiety drugs. Due to its potency it is a lot more addictive, and good for business. The media has not covered these facts, even as people died.

    No one confronted newspapers like the NYT, and WaPo for misleading the public and adding to the death toll. Mass Media has been spreading fear, hate and ignorance, while appearing to represent “both sides.” They are still using the word addicted to describe innocent infants, it gets more attention than presenting facts.

    The healthcare system profits by misleading the public and spreading misinformation, they have made billions on the so called opiate epidemic. People are dying, and they are still peddling Alternative Facts.

    Maybe one day we will look back at what they did, and recognize it as a Slow Genocide. The FTC refused to crack down on misleading health information and advertorials. Industry interests got rid of the Fairness Doctrine, so our media has no responsibility to tell the truth.

    Pharma continues to cash in, a lot of the other drugs up to one third of all “Overdoses” contained other pharma products. They actively marketed anti seizure, anti depressants and even anti psychotic medication as alternatives. The CDC did not count these deaths, and the media left them out.

    http://thefederalist.com/2018/01/29/big-pharma-fox-anti-addiction-hen-house/

    The media did not cover this either, as more people died from Fentanyl, they continued to harass, and threaten doctors and patients. The media and clever marketers are still conflating prescription pain medication and illegal fentanyl products mixed with other dangerous drugs.

    Drug wholesalers drove fentanyl’s deadly rise, study shows
    https://www.sciencedaily.com/releases/2018/12/181205093801.htm
    “Made entirely in the lab, fentanyl is far more powerful and much cheaper to produce than heroin, which is derived from poppy opium. It is usually sold deceptively — as heroin or brand name prescription drugs like OxyContin and Xanax. The researchers said drug users and street-level dealers, who may also be using the drugs, often don’t know whether they are taking or selling drugs adulterated with fentanyl, since it is added to the supply higher up the distribution chain. Therefore, the researchers said, demand from drug users is unlikely to have played a role in its spread.”

    https://www.sciencedaily.com/releases/2018/12/181205093801.htm

    It would be a lot less expensive to give heroin to the addicted, than to continue to pay thousands of dollars a dose for drugs that taxpayer funded research developed. These addiction drugs were relabeled and branded by corrupt pharma companies. The FDA bowed to industry interests so lying and profiteering are no longer a crime.
    https://www.rand.org/pubs/working_papers/WR1262.html?utm_source=STAT+Newsletters&utm_campaign=aee73122e4-MR_COPY_12&utm_medium=email&utm_term=0_8cab1d7961-aee73122e4-150732009

    Turning addiction into a reality show or entertainment clearly is not working, it was done to deliberately mislead the public.

    Another self described expert repeats Fake News, referring to a deceptive unscientific study, that got republished across the US. It is an example of the lies and deceptions of mass media. This shows why so many Americans are dying from Fentanyl.

    https://www.washingtonpost.com/opinions/another-harsh-truth-about-opioids-theyre-not-a-better-way-to-manage-pain/2018/03/09/0d2b6480-1287-11e8-9065-e55346f6de81_story.html?utm_term=.0da9e001fa1d

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