Last May, we published an article about the unintended consequences of the federal and state response to the Opioid crisis. Following that, we received a considerable number of comments that reinforced our contention that the policies that were instituted created considerable more turmoil and trauma than they alleviated. Here is a sample of what we heard. The names have not been published to protect the privacy of the correspondents:
“I have MCTD (mixed connective tissue disease). What that is is overlapping autoimmune diseases. I have 8 of them; Lupus, Scleroderma, Dermatamyositis and on down the line. It’s extremely painful. My body is literally eating me from the inside out. I have a pain pump in my stomach that’s connected to a catheter that runs up my spinal cord. It pumps Fentanyl 24/7 into that catheter and it goes to my pain sensors. I also take Oxycodone for break through pain.
Since the opioid “crisis” it’s become increasingly harder to get Oxycodone. One pharmacist refused to fill my script. I can fill it every 30 days but don’t typically do it but every 3 to 6 months. My pain doc says I should be fine because I have Scleroderma but that’s proven to not be true. He said he has patients with cancer and that are missing limbs that can no longer get pain relief.
The pharmacies are refusing to fill the doctors prescriptions. What’s going to happen is these people are going to move to street drugs, and/or commit suicide. When you’re in constant, uncontrollable pain you’ll do ANYTHING to get out of it. I know from experience.”
Another pain sufferer talks about not only the stigma of needing prescription pain relievers but also that the promise of “pain management” often turns out to be a mirage – and an expensive one:
“As one who suffers from chronic pain, I can attest to being made to feel like a lesser person with the intense scrutiny I have been subjected to. I have tried every option for pain relief known to me and my pain management doctors. I have undergone painful procedures that “promised” to relieve my pain for a year or more, only to realize that the effects of the procedures are much less effective than I was led to believe.
I subjected myself to physical therapy, selective nerve root blocks, epidural steroid injections, radial nerve ablation and acupuncture. I now am on a regime of opiads that I take daily. I thank God for these pain meds for without them I would have no will to live. Everyone experiences and handles pain differently so it is useless for the government to even set general rules that everyone should follow.”
And this individual makes a valid point about the absurd cost of pain medication coupled with the effects of government making them much less accessible for law abiding people to seek relief:
“I have suffered from chronic pain for a long time and a few years ago it got to the point where I had to give up my career as a nurse. Without pain medication I’m bedridden. In two weeks I HAVE to have a translaminar steroid injection or be removed from the pain clinic due to TN regulations. What used to cost me several hundred dollars a year now costs me thousands because of the ACA, higher co-pays and deductables and mandatory testing.
The ones misusing and abusing are NOT under the care of a physician and will turn to other street drugs when they can’t get opiods. The people paying the price are those following the rules.
I used to have random urine drug screens 1-2 times a year, now at least 4 usually 5-6 @ several hundred dollars each.
I used to go in every 3 months for a prescription with 2 refills at $25 a visit, now I go every month at $40 a visit. I have to have a yearly mental health evaluation and fill out a narcotics agreement every 60 days. If my second appointment falls at day 64 then I have to drive in on day 59 or 60 and sign the paperwork or I’m discharged. I’ve had to buy braces that the doctor said probably wouldn’t work, $550, or be discharged. It goes on and on.”
These comments are typical of thousands of other individuals’ personal experience.
Statnews reports that in a meeting, of the American Medical Association last fall, Dr. Barbara McAneny, oncologist and President of the AMA, relayed the story of a patient of hers that she provided a prescription for a pain reliever to ease his suffering from prostate cancer, which had spread to his bones.
“Metastatic prostate cancer in your bones hurts, and one day he called me to say that his pain regimen wasn’t holding him. So, I increased the dosage of his opioids from two per day to three and of course he ran out early,” McAneny said. “So, I called his primary care physician who agreed to write a prescription for his very large amount of time-release morphine.”
The pharmacist suspected my patient was a drug seeker and did not alert me that his prescription was denied. My patient, a very proud man, felt shamed and didn’t know what to do. So, he went home to be as tough as he felt he could be. That worked for about three days and then he tried to kill himself,” said McAneny.
Fortunately, his family found him in time, and the emergency medicine physician was able to save his life. He spent a week in the hospital and finally we got his pain back under control, on the exact regimen I had prescribed him as an outpatient.”
Among the most egregious results of Congress absolving their responsibility and allowing the CDC (Center for Disease Control) to overstep their authority, is the adoption of “prior authorization rules”, which allow healthcare insurers to second guess the professional judgment of doctors.
What’s involved here is the implementation by the CDC of “voluntary” guidelines that recommend substantial limitations of opioid based pain medication for patients suffering chronic pain. It makes no distinction for responsible individuals whose medical records contain no indication of misuse. ClinicalPainAdvisor reports that:
According to the National Conference of State Legislatures, as of April 2018, 28 states had enacted legislation setting limits for opioid prescribing, including restrictions governing the length of the course of treatment for patients newly initiated on opioids and caps on morphine milligram equivalents. The Department of Veterans Affairs codified the guideline’s recommendations into a statutory requirement 3 months before the CDC guideline was even finalized. Many hospital systems followed suit and imposed mandatory maximum dose standards based on the guideline’s recommendations. An extreme example is a law currently under consideration in Oregon, which if enacted would require that beginning in 2020, patients with chronic pain on Medicaid must have their opioid doses tapered to zero.
Since that report, 4 more states have followed suit, bringing the total of states instituting restrictive laws to 32.
Equally troubling is the fact that there was already an affordability crisis related to these pain relievers, but now even Medicare enrollees (Medicare Part D), are being told that the healthcare insurer is either putting their refills on hold, or denying them altogether.
Because of a Centers For Medicare (CMS) directive issued last year that authorizes pharmacists to fill prescription doses of between 90 and 200 MME at their discretion, prescriptions for anything higher than that range, may be – and often are, subject to review – (termed a “real-time opioid care coordination safety edit”), not by the original prescribing physician, but by personnel at CMS.
Medical insurers such as Anthem / Blue Cross and pharmacies like CVS (who, ironically are getting into the medical cannabis markets in a big way) have instituted hard policies on prescriptions as well. Follow the money, anyone?
Those patients enrolled in long-term care facilities, in hospice care or receiving palliative or end-of-life care, or being treated for active cancer-related pain are excluded from such screenings, but those patients that are not, constitute a significant number of Americans – one out of 18 according to recent estimates . That’s a lot of your friends and loved ones.
Chad D. Kollas, MD, medical director of palliative and supportive care at UF Health Cancer Center—Orlando Health, reports that in his experience, 54% of his patients have experienced stigma at a pharmacy counter and 75% have run into complications getting their prescription filled.
Michael Fratkin, MD, confirms what many other health experts have warned of as a consequence of the heavy handed interference from government bureaucrats. “The changing policies on opioids are leaving many patients in the lurch and suffering from withdrawal, which are essentially sending them to the street to use”, Fratkin says.
The upshot to all of this is that doctors are now highly concerned about being accused by the authorities of over-prescribing and leaving themselves open to possible criminal investigations and being brought before medical boards (google “California’s Death Certificate Project”).
The chilling effect trickles down to chronic and acute pain sufferers. The point that many critics of the new restrictive and intrusive policies, doctors and researchers alike, are making is that chronic pain patients are not at a high risk for becoming addicts and that such individuals are not in any way the center of the opioid crisis. The overwhelming majority of overdose cases are statistically found to be related to illegal street purchase and use of opioid substances – Heroin and now even more accessible, Fentanyl – a legal (when prescribed) painkiller that are being sold in different forms on the underground market. Legal prescriptions are decreasing, while at the same time opioid deaths are increasing.
No one should be surprised to learn that military veterans are acutely affected by the erratic and unreasonable manner in which the opioid epidemic is being managed.
The Veterans’ Administration notoriously over-prescribed opioid based pain meds for years, creating not only a dependency on them, but also a secondary market for the pills.
Instead of investing in the sort of therapies that restore the broken health of vets, doctors simply threw oxys, Vicodin, Percocet, Tramodal and others at the symptoms. Now, in a panic mode about the neglect and the consequential overdoses, they are shutting many combat vets down cold.
Psychology Today details the all too common story as represented by that of Craig Schroder:
Schroeder, a former Marine corporal, was injured by a roadside bomb in the “Triangle of Death,” a region south of Baghdad. He suffered a traumatic brain injury and lost some hearing, memory and movement. Due to pain from a broken foot and ankle, as well as a herniated disc in his back, he has had a steady supply of prescription opioids.
But after the DEA regulations were put in place to reduce opioid prescriptions, he was unable to get an appointment to see his doctor in North Carolina for nearly five months.
“It was a nightmare,” he said. “I was just in unbearable, terrible pain. I couldn’t even go to the ER because those doctors won’t write those scripts.”
His wife Stephanie told the Washington Post that getting her husband a VA appointment became her main mission in life, but she said the VA seemed to become hostile toward patients who asked for painkillers. “Suddenly, the VA treats people on pain meds like the new lepers. It feels like they told us for years to take these drugs, didn’t offer us any other ideas, and now we’re suddenly demonized, second-class citizens.”
As reported by PainNewsNetwork, researchers at the at the University of Pittsburgh, Carnegie Mellon University and University of Utah studied health data on over half a million Medicare beneficiaries who filled one or more prescriptions for opioids between 2011 and 2015. The researchers identified which patients overdosed and then used machine-learning algorithms to analyze their demographics and health records.
The analytic tools developed identified three risk groups and predictive models revealed that low risk patients (67.5%) have 0.006% risk of overdose; medium risk patients (23.3%) have 0.05% risk of overdose and high risk patients (9.1%) have 1.77% risk of overdose.
It is clear that patients receiving prescription pain meds are not the core of the epidemic. Far from it.
One patient , 56 year old Drew Pavilonis, a North Carolina resident whose surgery for a brain tumor left him wheelchair bound, told Politico that, “the medication controls my pain to the point that I can function independently – without it, I’m bedridden and pray for death.”
A pushback against the governmental and institutional overreach is now materializing and gaining momentum on social media. “We thought we should be the ones being consulted because you’re talking about taking our medicine,” said Lauren DeLuca, president of the Boston-based Chronic Illness Advocacy Awareness Group (CIAGG). The public policy advocacy group has a page on Facebook, chapters in several states and a website that will be of interest to those who find themselves in the circumstance we’ve outlined in this report.
And earlier this month an organization composed of hundreds of respected physicians and including former cabinet level health officials – Health Professionals For Patients In Pain, sent a letter to the CDC outlining the serious deficits in the CDC’s guideline regime. Of the regulations, they stated,
“Taken in combination, these actions have led many health care providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care.”
Whataboutism is in vogue these days, so let’s bring a popular one associated with opioids out to examine. The manufacturers of Oxycontin (Purdue Pharma) have been found to have instigated an aggressive marketing campaign with physicians, leading to cases of over-prescription of pain medication – what about that? For those who have been paying attention, aggressive marketing campaigns have been the standard practice of pharmaceutical manufacturers for over a century in the United States – for every variety of prescription drug. Opioids are no exception.
Where is the outrage and panic with the drug peddlers of all varieties of other (FDA approved) substances that carry extreme risk? Can you watch cable TV for 15 minutes without being subjected to a bombardment of “pharma porn” replete with exhortations of “ask your doctor” along with sublimated acknowledgments of risky side effects, up to and including … death?
The opioid crisis and the manufacturers are the bathwater and chronic, extreme pain sufferers are the baby that politicians, bureaucrats and social critics are throwing out with them.
It has to stop.