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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  • I visited my pain management today for my monthly visit. A new Dr took my appt who I’ve never saw before. She had no idea of my medical situation. I got annoyed that she was asking me questions that you’d ask a new patient. She then told me that my injury was caused by past car accidents. I’ve been seen by 3 spine specialist that have confirmed in writing that my injury has nothing to do with 1 near fatal car accident and 3 other accidents. She then told me that there was no pressure on my spinal cord when 3 spine specialist have confirmed pressure on my spine from spinal stenosis. I was then told by her with malice that she was cutting back my prescription. All because pain meds were found in my urine(morphine). Their prescribing me oxycodone and afraid to write the script every month. I was paying $30/month for my monthly prescription. Now that primary doctors can’t write narcotic prescriptions I’m paying pain management $150/month. They act as if they own me and I’m paying them. This has to change.

    • I so feel your pain. I too had to see a different doctor in the same practice. Who told me it was a SHAME to HAVE TO change medicine that CLEARLY HAD BEEN-WORKING for me, 9+years. BUT !!THE NEW LAWS !!!REQUIRE !!!us DRs to show proof we are actively working towards getting all chronic pain patients OFF OPIOIDS. Been a Chronic pain sufferer since 1996. Followed every rule always took my meds as prescribed drug tested every 3 months. Did all that perfectly with zero issues. And STILL AM treated like I AM a drug seeking faking criminal. I’ve been on most all alternative non opioid meds. THROUGH OUT 23 YEARS !!Which two separate times put me in the hospital. Been through the whole nine yards. I too am beyond angry. That someone who has zero clue about my case. Has made a law that has destroyed my ability to have ANY semblance of a life.

  • People-Please email or call your congresspersons! I’ve been reading this for months & I don’t think writing STAT does anything to help us. All we’ve gotten, for all the agony pored out here, is a feebly worded “clarification” by the CDC. And from what I’m reading, that hasn’t changed a thing.
    So much for the Hippocratic Oath. It means nothing. Nothing at all.

    • I agree with you Lisa. You can also go to whitehouse.gov and tell them your story. Until everyone makes noise in the right places no one will listen!

  • I am a victim of the new guide lines to reduce my medicine. Having been through the whole nine yards. Weeks ago I went to my regular pain medicine dr office for refills of my past 15 years regimen. Prior to this visit I had some semblance of a life. Able to participate in life’s semi normal life activities. Was told the new guide lines required them to reduce my pain meds. Even though He told me what regimen I was on HAD been working. Now I am stuck in bed in agony. Unable to participate in hardly any of life’s activities. I NOW SEE how a person who is not prone to depression or thoughts of ending ones life can happen. I have grand children. And it’s so heartbreaking to hear the little ones say na na is sick in bed. AGAIN. that is now a fact of my life. Thanks to people who never knew me. Yet made decisions that severely effected my ability to function as a semi normal human being. . My very existence is in this word is strongly jeopardize. For the sake of many like me please leave the doctors who KNOW their patiences in control of when to change their medications. Thanks to the new LAWS. I seriously don’t know if I can cope with this much pain.

    • Shirleen I feel your pain. I am the same way. My daughter given birth to twins in 2 weeks and I feel like I cannot do anything. I am so tired of being in pain 24/7 and now since the Sacklers are seeking to sell their Opiate business, we are really going to be screwed for those that depend on opiates to survive. What are we going to do, suicide. Many will. I want some of my life back before having 3 failed back surgeries. We have to get united as a whole.

  • I am one of those patients who have been on my pain meds since2003 and are having them taken away I live in N.Y.State I am 65 and suffer with severe Fibromlyalgia they have cut my script back last month and will continue to keep doing it till I am off completely they gave me a paper that said only Cancer patients can stay on their pain meds. Isn’t there some way to stop this injustice to these people that are circling the drain that got lumped into this herion/fentynol epidemic? I need help I am not going to have quality of life atleast on the meds I can function some what normally . Some one needs to speak up for us lawsuits or something it’s the hospital where my Dr. is affiliated with the Guthrie in Sayre, Pa. and they practice over into N.Y. State also big organization I’m sure the Dr. we’re told they had to do this . What can I/ we do please please help. People are going to go get illegal drugs on the street and get arrested or worse yet die from bad drugs or suicide . I am lost I have trouble with my email sometimes my cell is+16074265519

  • I am one of those patients who have been on my pain meds since2003 and are having them taken away I live in N.Y.State I am 65 and suffer with severe Fibromlyalgia they have cut my script back last month and will continue to keep doing it till I am off completely they gave me a paper that said only Cancer patients can stay on their pain meds. Isn’t there some way to stop this injustice to these people that are circling the drain that got lumped into this herion/fentynol epidemic? I need help I am not going to have quality of life atleast on the meds I can function some what normally . Some one needs to speak up for us lawsuits or something it’s the hospital where my Dr. is affiliated with the Guthrie in Sayre, Pa. and they practice over into N.Y. State also big organization I’m sure the Dr. we’re told they had to do this . What can I/ we do please please help. People are going to go get illegal drugs on the street and get arrested or worse yet die from bad drugs or suicide . I am lost

  • The “Drug War” is a huge 💰💰 money making business for local, state & federal government! Most people have no clue just how much money, vehicles, weapons, RVs, corvettes, Hummers, etc, the government acquires in the “war against drugs!” Why do you think so much effort and expense is applied to this issue? Check the budget of any police department in the country, and you will find the greater portion of funds are dedicated to the “drug war.” Then check the budgets for sex crimes, abused children, etc. and prepare to be horrified – these areas of crime do not produce revenue and can take a big bite out of the budget if appropriate funding were provided! Unfortunately, our Government (Federal/State/Local) has forgotten its purpose and the people it serves — does the phrase “… government of the people, by the people, and for the people …” ring any bells?

    The fact that legitimate pain patients were made inclusive in the Drug War to begin with, is not only reprehensible, but is, in fact, in direct violation of the Constitution as well as the laws implemented by the very politicians committing this travesty! Has everyone forgotten HIPAA (Health Care Privacy Act – 1996)? Under HIPAA we are guaranteed the right to privacy regarding our medical/pharmaceutical records — with Law Enforcement accessing these records only in the investigation of a crime. Unless a pain patient is involved in a crime, Law Enforcement, the DEA, etc. should be denied access to our medical records in accordance with HIPAA — this is not currently the case, the DEA is regularly monitoring the records of chronic pain patients for the express purpose of strong arming doctors into reducing pain meds – for no reason other than the DEA’s abuse of power!

    The only way to fight this is at the government level – and there is only one way left to fight government!

    Linda London

  • For Douglas Gearhart,

    AMA might be late to the party, but they have responded significantly in AMA House of Delegates Resolution 235 and AMA Board of Directors Report 22. The resolution reads in part:

    …Some patients with acute or chronic pain can benefit from taking opioid pain medications at doses greater than generally recommended in the CDC Guideline for Prescribing Opioids for Chronic Pain and … such care may be medically necessary and appropriate…

    …. AMA [will] advocate against misapplication of the CDC Guideline for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit patients’ medical access to opioid analgesia…

    ….No entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guideline for Prescribing Opioids.

    If your care providers haven’t seen this resolution, then print it out and show it to them.

    Best Regards,

    • Then why are Drs telling patients they have to cut their meds or force taper way below guidelines? I know what the guidelines are and I know that the CDC told Drs they weren’t meant to take patients off of meds that were working for that patient. So what are Drs doing? Are they being threatened by someone else?

    • I have been arguing with AMA in the State of New Mexico about this and how they are harming and taking away some people’s livelihood. I myself can’t take I ibuprofen because of water retention and can’t take acetomenaphen because of my liver so I only have pain meds that can get me up and moving. The AMA does nothing but fight against us. I wish some attorney would take up this fight on government level. Millions of people are doing without just because of the bad apples in the bunch. Well I’m tired of this already and I’m ready to fight. I pray that some attorney will climb aboard. Prayers to everyone that’s in pain.

  • I am on Enbrel a biologic for my rheumatoid arthritis. I have crohns disease and have taken numerous biologics that didn’t work. I cant walk or take care of my wife who has breathing issues from massive.amounts of blood.clots. She is on Adempis
    I find myself in a battle with my primary care physician over our usage of opiods. He won’t be satisfied until im off of them completely. This would shut me down from helping her and would probably send me into a severe depression resulting in my death. I have a need and i am qualified to have a comfortable life. Why is this happening to the good people who observe the rules and regulations The idiots that did this to themselves have ruined it for everyone else. This is way beyond my scope to understand what is going on. Is this what god gave us good thinking minds for. Take care of the people who hurt. The ones who worked 40 50 yrs. Now we just cut it off so no one gets help. That’s screwed up. Sorry i migjt not be hear next month. I am ashamed of the AMA No balls!!!!!!

  • First of all please understand that all congress members voted for stricter guidelines. Democrats & Republicans. Only 1 Congressman voted against the bill that was passed last year. Everyone needs to contact whitehouse.gov, your congressman, your President. Every Dr should be fighting for their patients instead of complying with such cruel guidelines. The DEA needs to stop threatening Drs & we as a country need to change our attitudes towards opioids. It’s modern pain medication to help people. It’s not an evil death sentence. Over 85% of people who overdosed did it from heroin fentanyl or a combination of drugs and alcohol. They’ve thrown pain patients into unrealistic statistics and it’s not fair or right. Fight back anyway you can. People in pain should not have to suffer this is 2019 for Gods sake.

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