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The Opioid Crackdown: Have We Gone Too Far? (Part I)
As someone who’s lived with chronic back pain for decades, I’m not unbiased about this matter. After trying yoga, (and still using) physical therapy, chiropractic, a back brace, mindfulness, my pain has gotten worse. (See my article, “Alternatives to Opioids For Chronic Pain.”) Over the past five years, I’ve developed severe scoliosis, worsening degenerative disc disease and spinal stenosis, plus various . Multiple procedures at a pain management clinic – from steroid injections to numerous radiofrequency neuroablation procedures – have offered limited and temporary relief. I’m now getting several opinions about surgery, which is no panacea for back pain.
Yet so far, I feel pretty fortunate. I can still exercise on various machines at the YMCA for an hour, four to five days a week. And I keep up pretty well with three young grandchildren. But I have to say that medically prescribed opioids – which I’ve been able to keep well below levels recommended as the upper cut-off by the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain – definitely decrease my pain.
However, many chronic pain patients live with nagging worry that recent efforts to curtail opioid prescribing practices of physicians will affect them. Some people are suffering because doses that allowed them to function have been lowered or they’ve been taken off opioids completely – even when they’ve had no problems with the drugs. Certainly, we went through a period of time when opioids were prescribed too freely and in doses too high (they often still are) – leading to the need for science-based guidelines for acute and chronic pain management; related education for medical professionals; monitoring (such as regular urine testing) of patients regularly taking prescription opioids; and prescription drug monitoring programs to collect and monitor prescribing and dispensing information about controlled substances.
However, concerns are being raised that the so-called opioid “epidemic” is leading to a crack-down on pain medications that has gone too far – not only causing problems for patients who need pain relief, but taking control from medical prescribers – creating divisiveness in the medical field, and in some cases leading to illicit drug use.
Who’s in Charge Here?
Even though the CDC guidelines are meant to be just that, voluntary guidelines – not “prescriptive standards,” with consideration for “the circumstances and unique needs of each patient when providing care” – what’s resulted are just some of the concerning policies and stop-gap measures being put in place by certain states, pharmacies, insurance companies, and medical facilities. Not all of these are “bad” things, as long as medical professionals have leeway in making decisions about prescribing for individual patients. However, they create real problems when they become mandates and/or one-size-fits-all rules. Following are some examples:
- According to a recent article in the Washington Post, as of August 17, 2017 at least 17 states have enacted rules to limit the number of opioid painkillers physicians can prescribe. “Some, including Arizona, Connecticut, Delaware, Massachusetts, New Jersey and Ohio, have passed laws limiting the duration of initial opioid prescriptions to five or seven days.” The paper reported that others are passing limits on dosage, while Kentucky just passed a law capping opioid prescriptions for acute pain to three days.
- CVS Pharmacy just announced that it will implement a policy limiting to seven days the supply of opioids dispensed for certain acute prescriptions, becoming the first national retail chain to restrict how many pain pills doctors can give patients. CVS is also limiting the daily dosage of opioids dispensed based on the strength of the opioid as well as requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed. (CBS reported that the initiatives will start in February of 2018.)
- The surgical department at Dartmouth-Hitchcock Medical Center in New Hampshire used a study published in the Annals of Surgery to create guidelines suggesting that surgeons limit prescriptions of opioid painkillers to a specific number based on the type of surgery a patient underwent. (I expect that a large similar study, published in JAMA Surgery in September of this year, will be used more broadly.) While certainly wise to base practices on research, and issued as a “suggestion,” my board-certified pain specialist pointed out that individuals experience pain very differently. So going by type of surgery rather than individual needs is less than ideal unless physicians can use their own discretion. He added that pain is very difficult to study because it’s so hard to measure. And as illustrated by practices initiated by the CDC Guidelines, suggestions often become rules.
There is a “civil war” within the medical community about the use of prescription opioids, as detailed in an article by Bob Tedeschi of STAT early this year. In it, Daniel Carr, M.D., president of the American Academy of Pain Medicine and founding director of Tufts University’s Pain Research, Education, and Policy Program, said that a growing number of doctors are being pressured into a zero-tolerance policy. “Because if one isn’t anti-opioid enough, there’ll be protests.” Several physicians I know have stopped managing pain patients because of their own fears about possible negative consequences for prescribing opioids, as well as concerns about how colleagues might view them. One told me that opioid prescribers are virtually scorned.
A Look at the Numbers
I’m not oblivious to the extent of the opioid problem in this country. At the substance use disorder clinic in which I worked, I watched clients suffer when it took lives of friends and children of friends. (Fortunately, we lost no clients this way in the three years that I worked there.) And opioid painkillers nearly wrecked the life of someone I love. (That person has long been free of them.) Hardly a day goes by that I don’t read about havoc created by opioids.
I’m not oblivious to the extent of the opioid problem in this country. At the substance use disorder clinic in which I worked, I watched clients suffer when it took lives of friends and children of friends. (Fortunately, we lost no clients this way in the three years that I worked there.)-Anne Fletcher
Contrary to popular opinion about the prospect of addiction to opioid painkillers, however, the National Institute on Drug Abuse Director, Nora Volkow, M.D. and renowned treatment researcher Thomas McLellan, Ph.D. state in a 2016 review paper in the New England Journal of Medicine, “Addiction is not a predictable result of opioid prescribing. Addiction occurs in only a small percentage of persons who are exposed to opioids – even among those with preexisting vulnerabilities [such as another type of substance use disorder, as listed in a separate table of factors that increase risk of opioid overdose or addiction.]” They note that rates of carefully diagnosed opioid addiction have averaged less than eight percent in published studies, while “rates of misuse, abuse, and addiction-related aberrant behaviors have ranged from 15 to 26 percent.”
This spring, in a Journal of the American Medical Association (JAMA) “Viewpoint,” two physicians addressing chronic pain management “in the aftermath of the opioid backlash” stated, “Excessive use of phrases like opioid epidemic should be avoided” because an epidemic usually suggests a disease that is widespread and highly contagious rather than limited to a minority of people exposed to it. They go on to describe a 2017 report of a large national pharmacy database which found that among more than 10 million new opioid recipients, the probability of transitioning to long-term opioid use was only 1.3 percent by 1.5 years – gradually increasing to 5.3 percent by 9 years. They concluded that only a small fraction of patients prescribed opioids progress to long-term use and “that among the subset that do use long-term opioids, the majority neither misuse or experience an overdose.”
Considering these facts and figures, along with more information to come, I agree with the following statement these two physicians made in their JAMA, “Viewpoint“: “The movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction.”
I would add that taking control out of the hands of physicians – or greatly limiting it and stigmatizing opioid prescribers – is part of this overreaction.
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