Punishing patients in pain won’t reduce opioid deaths

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A patient with metastatic prostate cancer tried to kill himself after he could not get the medication he was prescribed for bone pain because a suspicious pharmacist called his insurer, which denied coverage.

Barbara McAneny, the president of the American Medical Association, commented, “I share the nation’s concern that more than 100 people a day die of an overdose,” she said. “But my patient nearly died of an underdose.”


McAneny was talking about the suffering caused by government pressure to reduce opioid prescriptions, which has led to denials of treatment and arbitrary dose reductions across the country. A Medicare rule that takes effect on Jan. 1 will compound that problem, even as it becomes increasingly clear that the “opioid crisis” is driven by consumption of illicitly produced drugs rather than prescribed medication.

Last April, the Centers for Medicare & Medicaid Services noted that a proposed rule requiring insurer approval for prescriptions totaling 90 morphine milligram equivalents or more per day “was strongly opposed by nearly all stakeholder groups.” Physicians “opposed the forcible/non-consensual dose reductions due to the risks for patients of abrupt discontinuation and rapid taper of high dose opioid use,” the CMS said, while patients with chronic pain who have been functioning well on opioids for years “are afraid of being forced to abruptly reduce or discontinue their medication regimens with sometimes extremely adverse outcomes, including depression, loss of function, quality of life, and suicide.”

In response to the backlash, CMS changed the rule to require consultation between pharmacists and prescribers instead of approval by insurers. But in practice, the new requirement will further discourage prescriptions at or above 90 MME, even when they are medically justified.

The 90 MME limit, which comes from the opioid prescribing guidelines published by the Centers for Disease Control and Prevention in 2016, ignores numerous factors that affect how a patient responds to a given dose of a particular opioid. Those include obvious considerations such as the patient’s weight, treatment history and pain intensity, as well as subtler ones such as interactions with other drugs and genetically determined differences in enzyme production and opioid receptors.

The newly required discussion between the pharmacist and the physician may be hard to arrange, especially if a patient is trying to fill a prescription after office hours or when the doctor is busy. “If it takes a day or two to get that prescription approved,” says clinical pharmacist Jeffrey Fudin, “that patient may go through withdrawal.”

Lynn Webster, a former president of the American Academy of Pain Medicine, says the rule is bound to affect prescribing practices. “This is such a hassle for both the prescriber and for the pharmacist,” he says, that some doctors will “just keep the patients below 90.”

The new requirement “places the physician and the pharmacist in a confrontational position,” Webster says, “and the patient is going to be the real loser.” He worries that doctors will “basically abandon the patient’s needs.”

Last month, the American Medical Association approved a resolution condemning the “misapplication” of the CDC guidelines “by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit access to opioid analgesia.”

This month, a commentary in the journal Pain Medicine, signed by more than 100 pain and opioid experts, likewise warned that “nonconsensual tapering policies” can result in “severe opioid withdrawal accompanied by worsening pain and profound loss of function,” which may drive patients into the black market or make them “acutely suicidal.”

Opioid prescriptions, measured by total MME sold, have fallen by a third since 2010, while opioid-related deaths have more than doubled. Instead of reducing deaths involving opioids, the crackdown on pain pills has pushed nonmedical users toward black-market substitutes, which are much more dangerous because their potency is highly variable and unpredictable.

The Trump administration wants to cut opioid prescriptions by another third in the next three years. What could go wrong? We already know.

Jacob Sullum is a senior editor at the libertarian magazine Reason.

Creators Syndicate

2 Responses

  1. I was on the same dose for well over 10 years.I’ve tried 3 different pain managements in the last year and a half. The compassion is nowhere to be seen!!!! I started a new pain Dr. at the beginning of Dec. I was lowered again. I’ve been 100 % compliant!I am at bottom of my rope.

  2. My “out of pocket” cost for the particularly low cost to manufacture medication for pain management I have used for more than 20 years ( because of doctor/surgeon screw up) was only about $60.00 per month even before the absolute limit of 90 mme daily. There ARE pain management medications that do NOT cost much to make BUT, there is not much money to be made by the pharmaceutical company and dot/gov is not making money on peoples ‘misery so it has been declared as “dangerous”. It has helped me before the 2016 CDC “mis-guided-line” to be able to continue to own and operate my small construction business for decades but when the dot/gov “experts” conceived the idea that ALL pain management patients are simply “addicts” then, pressure was put on pharmaceutical companies to develop “better” tamper proof, abuse deterrent, VERY expensive opiate medications for those of us unfortunate enough to have debilitating, constant pain. SO, now that the “opioid crisis” has been declared the EASY fix is to create a “maximum” dosage of 90 mme which is NOT adequate for millions of pain management patients. My opinions are my own as a 20 plus year successful, benefitted from moderate use of opiate pain medication, pain management patient NOT of my own fault or indiscretions.

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