There are lots of blameworthy villains responsible for the prescription opioid epidemic – e.g., greedy/ruthless drug companies and distributors; careless/corrupt doctors and pharmacies; and a government overly influenced by big pharma lobbyists that was shamefully asleep at the regulatory switch.
Most of the villains have escaped meaningful accountability or righteous punishment. There are more than a thousand pending lawsuits, but so far no clawback of blood money earned and no pharmacy executives behind bars for acts that amount to massive manslaughter. The great hope is that, eventually, there will be gigantic fines (a la big tobacco) to help finance a nationwide network of free treatment for those tricked into drug dependence.
Meanwhile, the burden of the epidemic has fallen almost exclusively on the ten million victims, their families and communities, and local and state governments forced to pick up the pieces. At least three hundred thousand people have already died from prescription drug overdoses, and many more have died from street drugs obtained when legal sources ran dry or they were overtaxed by ever-increasing levels of tolerance.
The federal government’s response was far too slow in identifying there was an epidemic of careless prescribing that needed preventing. Now, adopting Trump’s typically impulsive and heavy handed approach, they have been far too fast in offering simple solutions to complex problems. Government directives have added significant injury to the already considerable suffering of those already hooked on prescription opioids.
Let’s Talk About Medicare Policies…
It is striking that one third of approximately forty-four million Medicare beneficiaries received prescription opioid pills in 2016. Of these, half a million Medicare patients were taking unusually high doses of opioids, and ninety thousand were found to be on extremely dangerous doses. About four hundred of the Medicaid funded doctors were especially high fliers, prescribing heavy doses to large numbers of patients.
Medicare clearly had to do something to tame the opioid epidemic among its beneficiaries. The most urgent regulation, and certainly the easiest, was to make it much harder for new patients with acute pain to get hooked on opioid meds they didn’t really need to be taking long term. Here, the new regulations Medicare introduced make great sense – limiting prescriptions for acute pain to just seven days. Previously, lazy docs were routinely and mindlessly prescribing a month’s worth of powerful narcotics to everyone as a way of reducing the incidence of annoying calls requesting refills.
But what to do with the millions already hooked? Medicare rightly recognized the obvious – that it makes no sense to artificially restrict opioid medication to end of life patients in palliative care, hospice, or long term facilities. The benefit of their continuing need for comfort medication far outweighs the risks in such situations.
Medicare’s mistake was in imposing arbitrary limits on the maintenance dose allowed for patients who are already physiologically dependent on opioid medication. Its top allowable doses are far below what many people had previously been prescribed as a holding dose. This could be construed as Medicare practicing medicine without a license. It has clumsily interfered in the doctor-patient relationship, providing strict general rules in what inherently must be a highly individualized, specific, and flexible process of deprescribing decision making.
Understandably, we have seen great outrage among large numbers of those patients forced (by the government) to experience and endure involuntary detoxification. Numerous anecdotal reports indicate that abrupt dosage reductions can push patients to use street drugs as a way to make up the difference and/or attempt suicide. The suffering is especially acute among patients taking opioids for chronic pain – the same patients who find detoxification to be especially difficult and sometimes impossible.
There is no one size-fits-all for those currently dependent on prescription opioids. Detox should be a voluntary decision and should always be done oh-so-slowly, under close medical supervision, and accompanied by comprehensive ancillary services that promote physical, occupational, social, and psychological rehabilitation. In most parts of the country, such services are either completely unavailable or unaffordable to those who most need them.
An adequate response to the needs of opioid victims will be provided only if there is a huge influx of treatment dollars, from government or pharma fines, but preferably both. It is unfair to blame the victims while requiring no accountability from the drug companies that caused the epidemic or the federal government that permitted them to get away with murder.
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