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 began to suffer chronic neck pain when i was in my early thirties.My regular doctor was retiring so he advised me to begin seeing a younger colleague at his practice.The new doc told me that if i ever reported back/neck pain again i would be banned from using their clinic.I returned to my regular doctor.He sent me for an MRI scan on my neck.SCAN/RESULTS..prominent lateral movement of a disk which was pressing on my spinal chord..the cause of my chronic pain..I worked in construction/electrician..use of my neck/looking upwards to work on lighting,essential…Fentanyl 150 per 3 days patches..i worked,i was also able to enjoy a loving relationship,holidays.I was reliant on opiods..now after a constant reduction of meds..i am unable to work..unable to earn money..single..at 50 i should not be thinking of suicide..all due to docs worrying about themselves/licence..

  • 66 yr/old male with chronic back pain cannot get opioid meds in enough quantities to go on a 34 day vacation, Medicare limits controlled substances to 30 day supplies. No allowances made for vacations or traveling. So I cannot leave my home for more than 28-29 days due to man dated doctor visits to obtain Rx scrips and 30 quality limitations. This is stupid and a violation of my human rights as a veteran and US citizen.

  • Well, only thing left to do is EVERY PAIN SUFFERER TO contact their gov’t officials, REMEMBER, ELECTIONS AREN’T THAT FAR AWAY, and let them know in no uncertain terms that their jobs are on the line. Demand they take U.A’s & if positive for opioids they should be forced to resign! THIS HAS GONE WAY, WAY TOO FAR. ALSO DEMAND INVESTIGATION INTO THE ” CONTRIBUTIONS BEING MADE TO THEM AND SEE IF THERE’S ANY TIES TO THE DRUG CARTELS !! WE MUST BAND TOGATHER.
    . ALSO, WHY ARE THE STATES SUING BIG DRUG MAKERS,? R THEY ADDICTED, DID THEY & ARE THEY SUFFERING,? SEEMS TO ME WE PAIN PATIENTS SHOULD BE GETTING SOME COMPENSATION ALSO, DR. VISITS AREN’T FREE. MAY GOD HELP US ON THIS, MATTER OF LIFE AND DEATH !!!!!!

  • It’s like taking guns away from law abiding citizens. It’s our governments answer to everything, take away from the good. What needs to be said and said loudly is that the majority of people taking prescriptions meds DO NOT ABUSE them and anyone who takes enough to overdose deserves whatever outcome they get. I have no more sympathy for people who do drugs to get high. They have made life a living hell for legitimate pain sufferers. The message our government is sending is for good decent people to suffer the consequences for what drug addicts have done. They take no responsibility whatsoever so let’s just take them away from everyone. Well it won’t work has never worked & never will work. Addicts will find something. Pain sufferers will suffer or be forced to buy on the street so yes there will be more suicides.

  • I just found STAT after searching for a Doctor that prescribes opiates without judgement.
    I read the newsletter. It appears to read that STAT is for opiod RX to be distributed for patients that have major Pain. My new Dr. is pushing unaffordable injections that do NOT work & everything but any opiates. My PCP of 15 years retired. She was my primary as abovementioned. I am w/ a new Dr. that speaks too much of his Boston area education & how he’ll work with me. What a joke. I was on a pain killer that is rarely prescribed. I knew this new facility wasn’t going to give same so I weaned myself off. My honesty with this new Dr. in 2 visits comes to the conclusion I have an addictive personality & my back is not as bad as it looks on rays Etc etc. I came this far getting off My pain killers so I’m all set? I was blown away!! My back is severe on paper!! My conditions come from years of laborious humping work. He’s on a “God” trip like many, unfortunately. SOME professionals have diplomacy & don’t use the “A” word. I have injuries that keep me in bed for days insomnia, MLLD, carpal, bakers cyst that’s been drained & back in FULL force, electric shocks from carpal, numb toes, knees give out. That’s on a regular basis. I need pain medications aka opiates to numb some of the pain. I don’t want to live with pain & NO ONE should have to. Legislatures poking their noses in this so called opiate crisis in the U.S. should look into other issues. Yes there will be O.D.’S accidental or intentional. Death happens! How about alcohol?? A drink to take the edge off! The only difference is it didn’t add a label on the bottles. This is a huge issue. I despise someone that is so lit up they stagger drive & kill someone. What is up? Opiates are needed for many & the stop on prescribing will kill more people. Some will go to the streets to find a drug. This is jacked. Solution= Maintain the prescribing of opiates!! It helps millions. It was made by pharmaceutical companies for a reason. To RELIEVE pain!! Money is involved but it is what it is. I will not give up on opiates. I have pain. Is STAT for or against? Is STAT a general notification type newsletter with varied points of view? I’M FOR OPIOID RELIEF! Government & other needs to back off. Please. Please!! My opinion there’s far bigger problems that are not being taken care of. RACING EXTINCTION Is a great documentary to show the bigger problems today!! Plus too many others to mention. Opiates need to be left on the shelves & distributed to the people in pain that follow directions, don’t overuse, & don’t have a dirty urine. So fun to whiz on my hands. (Joke) My tenure shows I’ve been 98%. No bad reviews from my PCP except I took clonazapam & a soma the pain was too much. That’s my story & I believe in relief! Thanks for reading.

  • As again I read thee authors of this article,,I can’t help but notice one of them is a civil rights/health policy lawyer???and why is it she will not help us sue the federal government for torture/genocide??Thee other thought I have is according to our government there are 3 million of us Chronic pain people due to painful medical conditions,,,,,,I can telll u ever since this government has literally decided to sanction torture upon the weakest in society,,the pre-existing medically ill,,,to save a buck,,,my view of this government is now,,,I hope they all rot in hell w/physical pain for eternity,,,,point being,,we are spreading the word world wide about Americans federal government agency’s torturing their own citizens literally till they die.This has effected the ####’s in those signing up for our military,,seeing their fathers/brothers/sisters forcibly suffer in physical pain because of the very government that sent them,,”They”’ the control freaks,the abuse of power,the perverts w/their power,,,ie A.K.,,have now willfully created another class of American citizens who hate their own government,,for good reason,,,their tortuing and killing us………jmo,,,maryw

  • I’m writing this at 3 am in the morning. I get 2 or 3 hours of sleep a night I’ve lost my job and now I’m worried about my marriage. They cut me down to 90mg and this is the result. I have 3 injuries in my neck, lower back and the middle. I have DDD, arthritis, bulging disc and more. I’ve been living like this for 15 years! I can’t have surgery because I have the worst insurance enough is enough. This really cruel

  • I am 49 years old and I am some what excerising my right as a chronic pain patient about this issue.
    It was 2004 when my intense pain started.. it started in my neck and back… granted I’ve had numerous auto accidents, horse back riding accidents , snow skiing accidents and more… in addition, both of my bio parents have the worse health I’ve ever seen!! So I got hit in every direction!
    I’ve been diagnosed with:
    *Primary fibromyalgia
    *Osteoarthritis
    *Degenerative Disc Disease
    *Both knees have to have FULL replacements
    *Congestive Heart Failure( already had stent put in at age of 37)
    *bulging discs from c4 —c7
    * spondlyonkg. Anklesosy( not spelled correctly)
    * sciatica in r leg that radiates down my leg and now it’s also in my left
    * bursitis in BOTH hips making it extremely difficult to lye on either side!

    And these aren’t the only things I’ve been diagnosed with!!!..there’s more!
    My point is this… I was put on OxyContin 2004 and my body although petite.. built a tolerance and by 2015 I was put on 80 mg of time release OxyContin… I took 2 per day is what my doctor prescribed for me…
    I took one in am asap when.i woke up and the other no later than 4–5 pm and just those 2 pain pills per day … ALLOWED me to live a SEMI normal life ( getting up and going to work, clean house, garden, take walks, even got to the point I was riding my bike all over our development!!!!) I could do things.. and yes I am limited in what I can do but those are simple things we take for granted every single day… until you wake up one day and simply can not do them anymore…. then what..?
    The opioids saved my young life and I felt like me again!

    But now… w all this b s going around.. I knew the sucicide rate would go out the roof bc police pretending to be doctors… I’m sorry what the hell have I missed??? If it’s that easy to be a doctor I want to sign up! No offense to law enforcement bc I have tremendous respect for them especially since they risk their lives every single day for us!!!!
    But really… why make pain patients suffer when there’s no legit reason too? It’s like we r living as cave ppl
    It is in humane to allow us to suffer bc no one locked their cabinets or was responsible for being a parent or just having simple common sense..
    I mean really!
    Example…. if someone has NEVER drank liquor before… why drink more then 2–3 drinks? They don’t know if they can handle it or not..
    And what have doctors taught us our entire lives??? That ANY medication has to be taken in moderation… they start us out on very low doses of whatever ( non narcotics etc) if that doesn’t work they increase the dosage… so why in the world would anyone (age irrelevant) decide to consume a dose of pain med say 15 mg , 20 mg , 30, 40, 60, or 80mg when they’re NOT used to it or it’s their first time trying it???? Especially when all we have heard is how potent and dangerous it is…
    That makes no sense to me …
    and I think it’s a nightmare so many ppl lost loved ones to overdose..
    but why make legit patients suffer for something we did not cause.???

    • You need to contact an attorney. AMA has guidelines about “abandoning” patients. It’s unethical and possibly illegal. We’ve had to threaten litigation to get a pain med prescription refill after my wife’s surgery. You need to talk about litigation with these doctors and ask them if that’s what you need to do? They will most likely back down. Also, in your corner when you talk to these doctors, remind them of the CDC’s April 2019 bulletin about not skimping too much on the pain meds. The doctors are going against the recommendations of the CDC’s revised recommendation. Any lawyer can win in court now. Link is here…. https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

  • I’m 64 still working been on opioids for over twenty years. I have severe back, neck, shoulder issues I live in pain 24 hours a day even on the meds and I’m still being forced to come back. My doctor is trying to keep me working as long as I can and it’s not easy I try to go off these and I couldn’t even get out of bed and I have well-known documented problems. Now I have severe neck cracking sweats I’m beginning to wonder if I have lymphoma. It doesn’t matter, what matters is that we are being throwing into the same category as the abusers. People wanting to kill themselves. They’re going to kill themselves regardless don’t punish us for that and I know it’s a lot of them are doing heroin among other things. I was watching report where this person was taking heroin and then you start saying she’s an opioid medication there’s a difference why don’t you treat those people with addictions and if you want people off this medication why don’t you give them a facilities where they can sign up for free maybe they can’t afford to help themselves. Let’s try taking care of the people in our country. Get them well, don’t cut them off. Work with them like you do with all the immigrants pouring in here. I’m a single woman, can’t afford rehab. That wouldn’t even solve the problem I have pain issues while knowing now it’s quality of life.

  • I read many of the comments here. I started having pain when I was 39 years old. I am now 62 years old and being told by my pain doctor that I have to reduce my use of opioids. She has reduced my opioid medications to over half and be still wants to reduce more. Unfortunately, I only respond half way decent to morphine. My quality of life is no longer manageable. I totally relate to those folks who have or consider suicide. I even though maybe I should go on a hunger strike to bring attention to the problem that chronic pain and how this is affecting people like me. I have written to my Senators, the President and other. There needs to be something done asap. Folks even some pain doctors have no clue what a person with pain has to endure i.e. feeling like a druggie, being treated very poorly by many. Honestly I could go on and on. However there needs to be changed. And everyone needs to contact their law makers, Senators, Legislative Representatives, President, Governor’s, etc. to let them know about this terrible problem. Hopefully you won’t ever get cancer or have to deal with deliberating chronic pain, but most likely if you don’t have to deal with this problem you eventually will know someone close who is or will be dealing with it. Please do your part if you would be so kind. Thank you very much for your help or for reading this. Bless you

    • Annie’s story is almost identical to mine, only difference if that I will be 62 in Sep, and my version is with VA doctors. I may live in a world controlled by my severe pain, but I am no where near afraid as my VA primary doctor. I cannot even get a straight answer from my medical team at the VA when I ask; Exactly what types, if any, of personal risks or diagnosis they have used to make these recent-drastic dosage and amount decreases to my methadone. Over 10 years of following every instruction from the VA concerning my opioid pain program /5 MG x 4 pr Dy. Now cut to 5 MG 2x pr day. The pain difference is enormous, but this fact is either ignored or disbelieved. This is no way to take care of a pain patient who headed every rule without incident for over 10 years. My sincere complaints of intense pain are just brushed aside. However, I am sure the VA’s government opioid dosage statistics are quite admired.

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