Opioid policy fallout

Opioid policy fallout | Medical Economics – Jeff Bendix – May 30, 2018

The epidemic of opioid-related deaths sweeping the country has lawmakers and regulators in Washington, D.C., and state capitals scrambling for answers. And while doctors generally welcome the attention to the crisis, many also fear that the solutions being proposed and enacted will do more harm than good.

The concern among physicians and public health and pain management experts is that laws and regulations designed to limit use of prescription narcotics, however well-intentioned, are yet another constraint on doctors’ ability to treat patients as they think best.  

Worse, they say, some of the limitations on prescribing could result in patients turning to heroin or buying the medications on the street. And because heroin in particular now is often laced with fentanyl and other synthetic painkillers, doing so astronomically increases the risk of death.

Balancing needs of patients versus the community

While opioid-related deaths have been rising for well over a decade, government efforts to address the crisis only got underway in earnest in 2016. That’s when the CDC issued its comprehensive “Guideline for Prescribing Opioids for Comprehensive Pain,” and President Obama signed into law the “Comprehensive Addiction and Recovery Act of 2016.”

Opposition to new CMS Rule

The most recent action aimed at reducing opioid use occurred in April of this year, when CMS approved a rule denying coverage (with some exceptions) for Medicare Part D beneficiaries whose total daily opioid dose exceeds 90 morphine milligram equivalents (MMEs).

The rule also limits coverage for patients receiving opioids for the first time to a seven-day supply, with no exceptions.

Bureaucrats making rules for medical treatment “with no exceptions” would override ethical medical treatment in some cases.

All these anti-opioid hysterics making these restrictive rules about pain treatment have clearly never suffered prolonged pain themselves.

The rule generated significant opposition from physicians and pain experts, dozens of whom signed a letter stating, among other objections,

  1. that the policy isn’t consistent with the CDC guideline, and
  2. it doesn’t include any metrics for evaluating the rule’s impact on patient health or access to care.

Among the letter’s signatories was Thomas Tape, MD, MACP, professor of internal medicine at the University of Nebraska Medical Center, and a member of the core group of experts that advised the CDC in developing its opioid guidelines.

When even the guideline creators oppose these new rules, it seems this would sow some doubt in the minds of the rule makers.

But, no, they just double down as they always have in their drug-war: the less effective a DEA policy is, the more money they throw at enforcing it, with no regard for the collateral damage it wreaks on our society.

And they are never held accountable.

I’m a firm believer of guidelines in terms of information to physicians regarding the hazards of high-dose opioid prescribing,” Tape explains. “But at the same time, physicians need to be allowed to exercise their clinical judgement about the appropriate course of therapy for a particular patient without interference from governmental entities, because there are so many exceptions to any general rule.”

I want to grab this guy and yell at him, “How could you not have realized that the guideline you were writing would be codified into laws?”

How can such a smart guy be so stupid not be suspicious when all the folks working on an opioid guideline for *pain* medication were addiction-ologists, without any pain specialists involved and mostly in secret.

Tape, who maintains a clinical practice, distinguishes between what he calls “legacy patients”—those who have been on high doses of opioids for months or years—and patients who’ve been prescribed opioids more recently and are still on relatively low doses.

One of the goals of the CDC guideline and subsequent laws and regulations, he says, is to ensure that patients in the latter group don’t become part of the high-dose group.

“But we also have to recognize there are no easy answers for dealing with that high-dose legacy group,” he adds.

You can’t just make the problem go away by saying we won’t pay for that kind of [high-dose] prescribing anymore, because that throws patients into a state of withdrawal.”

At least he has one thing intelligent to say.

Like Tape, Schwartzstein believes that getting patients off opioids, or just lowering their dosages, is a difficult process that has to be tailored to each patient’s needs.

“My primary goal is to manage chronic pain so that people can be as functional as possible, so I don’t take opioid pills away from people just for the sake of taking them away.

Hurrah! Here’s a doctor who still practices “real” medicine for his patients, treating them as the complex individuals they are instead of just numbers (milligrams of opioids) on a spreadsheet.

It’s all based on an individual assessment between myself and the patient,” he says.

That’s easy to say, but all the new rules based on the CDC guideline eliminate exactly the kind of individualized treatment he mentions.

Growing ‘opioid phobia’

For Dan Glatt, MD, an internist in Burlingame, Calif., specializing in pain and addiction medicine, obstacles to prescribing opioids have come not from any new laws or regulations, but from payers.

He cites the case of two patients who’ve been stable on their medications for several years, but whose insurance (which they get through their spouses who both work for the same employer) recently began limiting its opioid coverage to 90 MME per day, far less than the patients had been using.

I still don’t understand how supposedly intelligent people think that standardized doses for such a drug as opiods is appropriate.

That’s no different than assigning standard doses of insulin to diabetics, which also vary widely in their need for this medication.

Now, Glatt says, the patients are having to pay out-of-pocket for their pain medications.

In addition, Glatt notes that a growing number of physicians in his region now refer patients to him out of what he calls “opioid phobia.”

Docs who were prescribing now are afraid to because they don’t want to show up on a list or think the DEA is going to show up at their door,” he says. “They either want a blessing from me because they know I treat addiction and pain, or they just don’t want to take care of these patients anymore, even though the patient’s doing fine and has been stable on their meds for years.”

This shows how utterly these rules are divorced from treating patients as individuals.

Like many specialists in addiction medicine, Glatt believes the solution to the opioid crisis lies in devoting more resources to helping addicts and keeping outside interference to a minimum.

This is the real solution to our “crisis”, which is one of addiction in general.

Burdens on practice

Georgia, where internist Sandra Fryhofer, MD, MACP practices, recently enacted several laws aimed at curbing opioid abuse.

The law allows practices to assign up to two staff members to check the PDMP, thereby relieving physicians of some of the time required. Even so, “It’s going to be a burden because everyone is already busy in a small primary care office,” she says, adding that the process would be easier if the PDMP could be integrated into electronic health records.

The Medical Association of Georgia also lobbied unsuccessfully for a law that would have required commercial insurers in the state to provide coverage for opioid addiction treatments and opioid alternative treatments for patients.

It’s still cheaper to pay out-of-pocket for pain medication that try “alternative” approaches, like acupuncture and chiropractic, that require ongoing appointments to maintain the benefits.

“All these things are ways that we could keep from having to give patients pain pills,” she says.

Fryhofer adds that the law’s failure is emblematic of a larger problem:

Too few lawmakers, regulators and payers involved in trying to solve the opioid crisis truly understand its complexities or the resources the effort requires.

That’s because they’ve been flooded with misinformation put out by the anti-opioid zealots.

Tips for opioid prescribing

With all the legislative and regulatory efforts to reduce opioid use, can primary care doctors still prescribe the medications without running afoul of the law? The answer is “yes,” but experts caution that it takes work.

This is the bottom line: all these new regulations keep sqeezing doctors when they already have little “spare” time to handle all the paperwork and phone calls.

This is another insidious method of decreasing prescribing: place so many administrative burdens on opioids and threaten doctors with “enforcement” by the DEA if they prescribe “too many” (which is decided by the DEA, not a medical professional).

“If you choose to prescribe opioids for patients, the most important thing is to have properly documented records,” says Dan Glatt, MD, an internist and partner in a pain and addiction practice in Burlingame, Calif.

Anna Lembke, MD, medical director for addiction medicine at the Stanford University School of Medicine, also stresses the importance of documentation, along with determining if the patient has a history of addiction or substance abuse.

The case for outside intervention

Anna Lembke, MD, knows that where government regulation of opioid prescribing is concerned, she is an outlier.

Lembke thinks that reducing opioid use requires intervention by legislators and other outsiders.

For this alone, I would argue that she cannot be a professional doctor. Real doctors always treat each individual according to their individual background and individual needs.

No government can legislate standards for what treatment patients truly need and still call it “medical care” – this is something only a doctor working with each individual patient can determine.

Lembke’s willingness to accept government-imposed limits on opioid prescribing is based on the need to counter what she calls “perverse incentives” in the nation’s healthcare system to overprescribe the medications

Among these incentives, she says, is the influence that pharmaceutical manufacturers have wielded, and continue to wield, over organizations and agencies meant to protect patients and advocate on their behalf.

She points to a March 2018 draft report to the director of the National Institutes of Health recommending, among other actions, that the institute no longer accept funding for public/private partnerships from pharmaceutical companies involved in opioid-related litigation.

The growing number of physicians leaving private practice to work for hospital systems creates another reason for doctors to overprescribe opioids, she says.

Still another factor favoring opioid prescribing, Lembke says, is Americans’ attitude towards pain. “In general, I think the cultural trend is toward the belief that any amount of pain is too much,” she says.

That is exactly wrong: The attitude Lembke describes would only be held by what our culture thinks are sissies and wimps.

Americans believe you should “suck it up” – pain patients are told that all the time.

And while that attitude stems from a variety of causes, the pharmaceutical industry promotes it. “Their attitude is, ‘If you’re experiencing any pain, you have an illness and your doctor has a responsibility to treat that,’” she says.

No, this isn’t an attitude problem, it’s apublic health problem that’s not being addressed. Our treatment of pain is so poor that Human Rights Watch is Investigating U.S. Pain Treatment.

6 thoughts on “Opioid policy fallout

  1. Scott michaels

    Patients have been fight this along with only a few dr.s ITS TIME DRS GOT OFF THIER ASSES AND FOUGHT FOR PATIENT RIGHT AND OPIOUD PAIN RELIEF. IF THEY STOP BEING SUCH PUSSIES AND SAY WHAT THEY K OW. OPIOUDS HAVE WORKED FOR OVER A THOUSAND YEARS FOR PAIN. IT IS THE GOLD STANDARD. BECAUSE JUNKIES GET A HOLD OF PAIN RELIEVERS ILLEGALLY AND USE HARD VORE DRUGS LIKE HEROIN AND COCAUNE ETC. PAIN PATIENT MUST NOT BE THE TARGET OF THE WITCHHUNT. IT MUST STOP NOW. UNLESS YOU NEED THE MEDICATION AND TOOK IT FOR A DECADE LIKE MILLIONS OF US. YOU DONT KNOW ANYTHING. PERIOD!!!

    Liked by 1 person

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  2. canarensis

    I saw elsewhere that “Ohio’s Board of Pharmacy says about 225 million fewer opioid doses were dispensed to patients in the state in 2017 than in 2012.” And says “the amount of opioids prescribed to its members has decreased 40 percent over the past 18 months…it plans to reduce that number by 50 percent by the end of this year.”

    Sooo…is it just me, or are they saying “we’re in the middle of this dire epidemic caused by pain medications, it’s getting worse every year so we’ve gotta cut down the # of pain medications” while simultaneously saying “we’ve already drastically reduced the # of pain meds for years.”

    Do they actually fail to see that this makes absolutely no sense –they cut the Rx’s way down yet the ODs have been going way up, so –logically– maybe the # of pain Rx’s isn’t the problem? Or am I still idiotically naive & stupid to think that logic should apply to any part of this insanity?

    Ran across a tirade in a book yesterday by an author I otherwise like, which seemed to be pushing the idea that global warming either isn’t happening or has no human-caused element. He said “snow & ice & cold aren’t normal for the Earth,” and that at least 100,000 of the last 200,000 years were taken up by Ice Ages, which are rare [far as I can tell –statistics weren’t my strong point– something that occupies at least 50% of anything isn’t “rare”]. Then he went on to say we couldn’t be behind global warming b/c Nature & Climate are so strong that not even atom bombs could damage glaciers, which could come back any time.

    That was about as coherent as the Ohio “rationale.”

    “Bureaucrats making rules for medical treatment “with no exceptions” would override ethical medical treatment in some cases.” Oregon is about to cut off all opioid treatment completely for all chronic pain or fibro cases, no exceptions –not even limit to the 90MME. Clearly they don’t give a rip about ethical medical treatment.

    Liked by 2 people

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    1. Zyp Czyk Post author

      I hope this is the kind of extreme that wakes people up about what’s going on.

      Notice the first legislative restrictions were fairly tame, but then escalated over the years as each group sought to be the “toughest”. Eventually, inevitably, they finally do something so absurd that it breaks their spell of righteousness.

      Liked by 1 person

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      1. canarensis

        I really hope you’re right, but from reading the news (more often than is good for my stress levels) I have grave doubts about anything being too absurd to break their spell of righteousness (outstanding phrase, btw!).

        I ran across this in a book by Mary Roach a little while ago, & it seems particularly apt:
        “. . .the most staunchly held beliefs are based on ignorance or accepted dogma, not carefully considered accumulations of facts” (from “Spook”). And thus are devilishly hard to contradict with facts; when facts can’t touch belief, where the heck do you go next?

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  3. sharonaowen

    Did you know that thug drug dealers ACTUALLY deliver their drugs like illicit Fentanyl to your door like a Dominos Pizza? I did not know that until April 29th, 2017 in the dark damp hours of a rainy spring pre dawn hour. As I may have mentioned to many in my group, my younger brother died just last year in April 2017 of a Heroin/Fentanyl Overdose. I ❤️ my brother immensely, always have, always will. The sheer pain of his death alone saddens me. What makes matters much worse is knowing that the sins of my own brother (and many JUST like him) would inadvertently affect my pain control just a year after. It’s like double the pain — and it honestly plays tricks with my head. I understand the opiate epidemic — but honestly, my brother didn’t actually die of a Heroin overdose. You know what he died of? He died of a Fentanyl Overdose. Let me tell you, the medical examiner was absolutely dumbfounded and shocked at his toxicology report. The amount of illicit Fentanyl in his system was one of the highest he has seen. More than 4 shots of Narcan couldn’t touch the amount of illicit Fentanyl that was in my brothers system/blood stream. Seeing him lying there dead on the basement floor is a sight I can not unsee. I wished I had not looked because that was NOT how I wanted to remember my brother.
    My brother had an ADDICTION!

    In the other hand, chronic pain sufferers have a physical /chemical DEPENDENCE on the opiate — big, big, HUGE difference. But the mass media has been taught otherwise. The pharmacist, the news outlets, many in the general public, physicians, the government in general, ect. do NOT know the difference between the two. And they want to lump BOTH the chronic pain sufferers in the SAME bag as folks just like my brother who, unfortunately brought an addiction upon themselves (not purposely) but nonetheless, his disease brought about his own demise.

    Last but certainly not least, the Mexican drug cartels and the drug smuggling in from countries like Canada and Mexico are to blame for the illicit Fentanyl abuse, and more importantly deaths/overdoses. Why? Illicit Fentanyl is coming from a much more potent drug — a elephant tranquilizer called Carfentanil. This drug has its appropriate uses — but when you put a drug meant for 8,375 pounds animal in a human being with let’s say an average size of 137 pounds, it is an ABSOLUTE recipe for disaster! I mean, come on, even the first responders don’t want to touch this stuff. Even the smallest amount of powder wiped on a hand can absorb into a persons body and cause an overdose.

    Carfentanil is an analog of the synthetic opioid analgesic fentanyl. A unit of carfentanil is 100 times as potent as the same amount of fentanyl, 5,000 times as potent as a unit of heroin and 10,000 times as potent as a unit of morphine. So go inject some of this stuff, only it is sliced, diced, and laced with a little other “Great Stuff” for your body like baby powder, a little bit of Heroin to boot, even some Valium. There you go! They wanna make this stuff good so you get hook, come back for more, send referrals, and become a customer for life (or whatever amount of life the drug dealer can get out of you)! Then when you die, they just move on to the next Tom, Dick, or Harry!

    This illicit use of Fentanyl, cut from Carfentanil, is honestly, in my humble opinion, the worst conspiracy hidden by the government for some time. Why? I think because they know they are losing the overall war on drugs. If you think about it, if you were in charge of drug control into the country, wouldn’t it be quite embarrassing to know that people from OUTSIDE our country are actually smarter and more instrumental at smuggling this drug in successfully and they simply don’t know how to put a stop to it than you do? So what a better way to shield their own embarrassment by blaming a completely different set of people as the problem — chronic pain sufferers. How inhumane.

    Grow some ball governmental agencies, get your act together. Figure out how to STOP this insanity of this elephant drug getting into OUR country that is the TRUE cause of killing so many people!

    If we could manage to put a man on the moon nearly 60 years ago, why in God’s green earth COULD’NT we stop this deadly elephant drug from becoming so pervasive in our country?
    I would love to know the answer!

    ~ Sheri Owen
    Chronic pain sufferer & Sister of Vincent Winterer, just 1 tens of thousands in 2017 who died as a result of illicit Fentanyl in his system 😢

    Liked by 1 person

    Reply
    1. Zyp Czyk Post author

      I’m so sorry about your brother. Both he and you are collateral damage from the drug war, that war without end.

      We can’t win it and we don’t want to “give up” and “surrender” our foolish ideas about a “drug-free world” (except alcohol and tobacco, of course).

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