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.

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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.

  • A psychiatrist at the San Francisco VA has recently been accessing patient’s private records then picking up the phone and calling all their providers to tell them the patient is a drug seeker and Dr. shopper there is no basis for these accusations in by VA law she’s banned from doing such things the providers were horrified and it only lend credibility to the patient’s complaints as all had been handpicked by a prominent local physician the sad thing is the VA didn’t seem appalled at this rug Physicians actions more innocent people are going to dieAs a result of the DEA and FDA’s ridiculously ignorant conclusions those medications were designed for a purpose and they cannot be substituted by antidepressants and anti-convulsant all the physical therapy and meditation in the world will not deal with the kind of pain and humiliation these patients are now in during. Thank you very much for publishing this we have a long way to go but I have a little hope will make a difference

  • There are a few facebook groups that focus on this. One that I’m in is where MANY of us are sharing info of course, but the admins of that group are actively seeking legal assistance to fight against this travesty regarding helping those of us who suffer. They keep the latest news posted as well. I highly recommend you all go & join. Doing this will help us to keep up with the most current information & help us to unite. Please come join! I’m continually praying for all of us who are suffering needlessly. Here is the face book link for “Chronic Illness Awareness & Advocacy Coalition”. https://www.facebook.com/groups/239095889958781/

  • Ms.Procter,i am sorry to hear of ANOTHER good man,good doctor, who’s life is destroyed for practicing medicine.I wish ALLL the doctors who were unlawfully arrested,destroyed,and assets stolen by our Federal Government would speak out!The TRUE history of all of this needs to be recorded and told,for future generation..U all know dam well,,just like they did to our soldiers of all wars,,they will just label this a lie,,by liars.Those lies being,were addicts,,truth being told,we are pre-existers medically ill in forced physical pain,Our Federal government sanctioned torture/genocide of the medically ill,for $$$.Arrested any who practiced medicine w/the use of a medicine called opiate medicine,,thats the truth they will censore for history,,they’ve done exactly that before!!..I wish all the good doctors would get the truth out,they were arrested,their lives destroyed for practice medicine..jmo,maryw

  • Good for you all! Keep expanding til we stop The useless deaths in incarceration of sweet caring Physicians like Dr. Thomas Keller a retired Air Force neurosurgeon who is now in prison probably for the rest of his life and find over $14 million because of a an unethical pharmacist at Dollar drug. Don’t delude Your selves I have concrete documented evidence that CVS pharmacy was diverting thousands of dollars and thousands of pills of controlled substance is using my name and insurance yes over 900 hydrocodone in 30 days excuse me in six months that were never given to me 400 over three days CVS needs to get in line and we’ve got to get the corruption out of the DEA who in my personal experience as told by an ex agent loves to lie cheat yourselves I have Conn create documented evidence that CVS pharmacy was diverting thousands of dollars and thousands of pills of controlled substance is using my name and insurance yes over 900 hydrocodone in 30 days excuse me in six months that were never given to me 400 over three days CVS needs to get in line and we’ve got to get the corruption out of the DEA who in my personal experience as told by an ex agent loves to lie cheat andAnd steel in the course of their pathetic investigations designed to do nothing but serve them self I don’t know what this country is coming too but this adversarial system of healthcare has got to end and put the power back in the Physicians and let them practice the medicine they learned in medical school not with the corporations dictate to limit patients lives and terminate them early

  • I am 81 years old and just had a knee replacement 14 days ago in Florida. I have complications- Patella deviated to the outside and a large hematoma. My surgeon cannot by law prescribe opiates after 7 days. and as far as I can tell, neither can anyone else. I can’t take NSAIDS he usually prescribes. I spent 4 days lying in bed crying in pain. When I get the additional surgery they say I will probably need, I’ll be getting it in another state. Considering Georgia or Texas. Any recommendations?

    • I’m so sorry you have to go thru this! I would definitely make sure whoever does the next surgery that you tell them what you’ve had to go thru & make them promise they’ll cover your pain & for how long. It’s time we talk back to these doctors, telling them that our rights are being violated! Would they take away anti-anxiety or anti-depressants from patients who have been depending on them for a more normal comfortable life? No! Why? Because they don’t want them to suffer! Then it doesn’t make sense that they’re allowing pain patients to suffer? Is it discrimination? Is it abuse? It IS inhumane for sure. I wish I could help you in some way. Please keep us updated. I’ll be praying for you

    • I live in the state of Texas and it’s not much easier to get needed meds.
      I do feel sorry for you and the millions of people like us that suffer daily.
      It’s bad enough going thru life as a pain patient alone without the government making us suffer more.
      I like most others aren’t able to go places to protest.
      I’ve been giving it some thought and maybe somehow we could start some kind of petition and all sign it get it on everyones desk that might help.
      Other than that street drugs might be in order.

  • To find rallies near you go to dontpunishpainrallies.com. We’re going to have to show up & be counted to fight this.

    • Joe,,I get it,,your tooo sick to stand in the cold for hours protesting,,,me too,,,,,There is a 3rd option if u can wait 1 more year??and I know,,that is a really big if???,,I fully believe u have a right to die,,,and that’s not why I am replying,,,I am simply giving you info for a 3rd option..When the government is torturing and killing the pre-existers,,for all of us CPPP,,,are pre-existing,and god knows they have been trying to not pay for us for every,whilst the ceo of BC/BS,AETNA,HUMANA,ETC ALL MAKE 16 MILLION OR MORE,, to kill us,,,sanctioned by this president..When the system fails us,,,we make our own system..The 3rd option is ,,grow your own pain medicine…All of us CPP’s are very very intelligent people,,,if some scientist in a lab over 100 years ago,with a little fire and alcohol,could make a pain medicine from a little flower,,,well,,,,u figure out the rest..The way I see it,If death is the option I am reviewing to stop my physical pain because America’s government has sanctioned torture,murder and genocide of the weakest in society,us,the medically ill,,,then why not try to make my own medicine.If I die trying,,so what,,,no-NORMAL HUMANBEING would want to live the rest of their life in forced physical pain,ie,being physically tortured everyday of their life,,,Just a Idea,,Mr.Marzouk…Also there is a huge anti-opiate conference going on the Wisconsin,,April 23rd thru 25th,,,in the Wisconsin Dells,,at a resort called the Kalahari…All your anti-opiate ,,all the torturer’s ,murder’s and genocider’s will be there under 1 roof,,,just fyi,,,maryw

  • My pain management doctor told me that he’s cutting my meds by 10 pills per month regardless of what I say or think.
    I have called 10 other clinics that are offering no pain meds.
    I have a spinal cord stimulator that has caused me more problems than help.
    I have had steroid injections that don’t help so they want me to try a pain pump.
    I’ve done my research and found that it’s the last thing I need.
    I’m down to street drugs or ending my life.
    Someone stated that it’s a long term fix to a short term problem but I don’t see it that way.
    It’s a long term fix for a long term problem because my pain doesn’t stop!!

    • Joe, you need to copy the new CDC guidelines & take it in to your doctor! The CDC is admitting the guidelines have been misapplied, causing people to do just exactly what you’re talking about. I know the pain is horrible but since this has come forward I believe we have some hope. Literally hundreds of doctors are standing up for chronic pain patients, & sent a letter to the CDC with all their signatures. It has caused the CDC to resubmit the guidelines clarifying that they have been misinterpreted, saying that doctors must focus on whats best for the patient. In the original guidelines it even says the doctor & patient should talk about what’s best without reducing or totally cutting people off. Doctors doing anything like that would be violating a patients right to have appropriate health care. Please, try at least once to take a copy of the actual guidelines in & insist on the doctor viewing them. How can they justify doing anything to harm a patient after reading them!

      Also, I know, you’ve probably heard enough from Jesus freaks already. But honestly, the Lord seriously loves you & wants you to turn to Him. Suicide is a permanent act. There is an eternity & you really don’t want to make any harsh decisions when, you have to admit, the life beyond this one could be worse if you’d follow thru with suicide. And you would never be able to change that decision. My heart is breaking for what you’re going thru. I too have pain. I’ve always been going into my doctor acting like the victim but, I’m done doing that. We have to stick together & fight this! Esp since the CDC & DHHS backs us now! I am already telling my dr (sent an email today) that I have just as much right to have some quality of life as they do & I won’t allow someone that has no idea the pain I’m in to make destructive life decisions for me. I’ve also said that if they cannot help me I need a referral to a doc that can. They are suppose to do that anyway. I’m being courteous but very firm & confidant. Please, just try it. Keep us updated how you’re doing. I WILL be praying for you! Here is the link below.
      https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html

      Copy this info, highlight the area where it says
      “The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.”
      Of course it’s up to the doc but since the CDC is claiming drs have been misinterpreting the guidelines, they should get serious about it & not so afraid of the CDC

    • Before ending your life, try fighting. If you’ve already called/emailed every congressperson you can find, go to rallies. Shout & carry a sign. Write to journalists & news outlets. Fight!

  • What do we do to stop this unfair treatment of us elderly patients that live in cronic pain? The ones that have never abused their medication or used any type of illegal drug. Those just trying to survive this horrible pain that leaves you unable to live a normal life. The doctors cutting our meds back is never going to stop the addict. I know these people, I’ve watched the damage they do. I can assure you it’s not from taking their meds as prescribed. This is a terrible injustice to the average person that needs to stay on their medication without being cut back for no good reason.

  • I’ve decided to fight this, confidently letting my doc know that I deserve quality of life instead of being treated inhumanely! I have researched the heck out of this stuff & found the following:
    ~”While the CDC guideline was intended to provide nonmandatory suggestions for primary care physicians, in practice it is often being implemented in ways that go beyond its intent.” In a report from the DHHS, to propose updates to the CDC guidelines. The report, released in May 2019, recommends a “balanced, individualized, patient-centered approach,” including more time spent between clinicians and pain patients to develop a plan for enhancing quality of life.”
    ~”In March 2019, more than 300 medical experts signed a letter to the CDC addressing the “widespread misapplication” of the guideline. They asked the CDC to evaluate the guideline’s impact and investigate reports of suicide and increased illicit drug use. They called on the organization to issue a bold clarification” of its recommendations regarding opioid dosage, tapering, and discontinuation.
    ~As a result, the DHSS issued new guidelines in October encouraging doctors to involve patients in decisions about opioid tapering and consult with them to ensure they are not experiencing adverse side effects.”

    People! We NEED to start putting THIS in the faces of our doctors! Anyone want to chime in on your thots on this??

    • I too would love to join somesort of “march” a public out cry to whoever is misusing the CDC’s guidelines. Yet all of us who are suffering from pain can’t physically join a “march”. it would take a court action and we don’t know who to stop the misuse in court. No wonder many are considering suicide to stop the pain with no relief In sight. Bless all of you

  • Georgia’s first “Don’t Punish Pain” rally will be March 28th, 2020 (Saturday) from Noon to 2:00 pm at Redwine United Methodist Church in Gainesville, Georgia. ATTEND! PASS THE WORD! To fight this, we have to FIGHT it! Go to dontpunishpainrally.com for more information.

    • How do we find out if any events like this is happening where we live. I’m in Oklahoma and I would definitely participate in something like this. I’m sick of irresponsible people causing my life to loose value. Help the addict for what they are. Taking my medication is going to make one bit of difference in the self destruction.

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