Hardly a day goes by when the discussion of opioids and their misuse is not on the front page of local or national newspapers. However, the flipside of the issue, pain management, is barely, if ever, centered in the conversation.
This came up most recently with Republican Sen. Rob Portman of Ohio, who seeks to advance a bill he previously introduced called the Comprehensive Addiction and Recovery Act 2.0, which would, among other things, establish a three-day limit for opioid prescriptions.
This lack of focus on disabled and chronically ill patients has inadvertently pitted doctors against their own patients, who are framed as going down the rabbit hole of dependency following a sprained ankle or routine dental surgery. But this overly simplistic framing erases people with long-term disabilities and chronic health conditions who are struggling to live their lives while being punished for using the best tools we have available to enable their full participation in society.
The Centers for Disease Control and Prevention (CDC) in 2016 offered strategies to taper patients off opioids, but left doctors and patients with their decision-making authority, as it should. However, while the CDC clearly intended the guidelines to be just that—recommendations—that’s not how they’ve been interpreted.
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As of last fall, 33 states have put policies in place that limit a person’s access to pain medication, in some cases to three to seven days of medication with no available refills. In some states, this means that patients are forced to go back to the doctor, enduring the burdens of medically unnecessary appointments just to get a new prescription, in order to get the medication they need every seven days.
These are people for whom opioids allow them to go to school, work a job, and manage their home life. In the words of Maelee Johnson, a disability advocate, in an interview for this piece: “Dependence isn’t addiction, and that is continually left out of the discussion and the policies being made.”
This costs lives, Johnson added. “Since the opioid crisis became a political issue, I’ve lost access to all my medication, and I dread having to convince doctors that I need these meds to survive again. The consequences of this are very far reaching.”
It’s not a legislator’s job to diagnose a patient’s ailment or prescribe relief. That responsibility falls to clinicians, who go to school for years for this specialty. And yet, time after time, lawmakers in Congress think they are equipped to address the complex needs of millions of individual patients with their policymaking. In the case of Sen. Portman’s bill, this is especially concerning in light of data pointing to the disastrous impact of arbitrary day-centered limits on pain treatment.
While this bill and similar efforts—including one by Democratic Sen. Kirsten Gillibrand of New York, whose recent policy announcement ended in her pledging to work more closely with the disability and chronic health communities to fix her bill—have an exemption for “people with chronic pain,” this approach fails to take into account what that will mean in practice for actual patients.
Research shows that even when there are exemptions, the patients’ needs are overridden as physicians fear being punished for over-prescribing medication. “Despite exemptions for [chronic pain] patients in the CDC Guideline and Tennessee state law, [a nurse practitioner at Vanderbilt University’s hematology department] had seen a major push from state regulators and insurers to get [sickle cell disease] patients down to lower doses,” noted a 2018 report from Human Rights Watch.
The report showed that legislative interventions such as these do have an impact on the quality of care doctors can provide to their patients who live with chronic pain. Doctors are interpreting the CDC guidelines and congressional action as broad, iron-clad requirements, and patients and people with chronic illnesses are the ones struggling.
Every person experiences pain differently, and legislation addressing this issue needs to take that into account.
Evidence shows that policies inserting the government into the doctor-patient relationship don’t work. For one thing, the majority of people with addiction issues tied to opioids do not receive them from a medical professional. Rather, they receive them from a friend, colleague, or they purchase them on the black market, according to data from the Substance Abuse and Mental Health Services Administration. Furthermore, the U.S. Department of Veterans Affairs, when working on limiting access to opioids among its community, issued a report in 2018 that clearly showed how restrictions did not result in fewer veterans overdosing. It resulted in more veterans dying by suicide, according to the research.
If you enact a policy and it results in constituents dying, it’s a bad policy.
This is what happens time and time again when policymakers craft legislation based on “good intentions” versus tapping into the deep expertise and “lived experience” of the disability community.
Inconsistent enforcement by the Drug Enforcement Administration has also led physicians to be concerned about the prescriptions they’re writing for patients. But it isn’t just the DEA pressuring and arresting physicians; when government intervention is not successful, insurance companies may meddle in complex patient care decisions. The America’s Health Insurance Plans (AHIP) has announced it will begin to track how physicians are complying with these new policies. Though this surveillance data will not be released to the public initially, there is little doubt it will be used to track the preponderance of opioid prescriptions.
This will compound the pressure already on doctors to not diagnose people with chronic pain and will lead to a decrease in access to pain management.
Additionally, there is a concern we will see an expanded list of drugs under restriction; we have already seen anti-seizure and anti-anxiety drugs like gabapentin included in recent state regulations. Broadening what drugs are included will undoubtedly expand who is affected. As we saw when allergy medications became restricted due to their use in manufacturing crystal meth, many times a medication that could be used to combat one symptom could be used for a nefarious purpose.
Instead of trying to force a flawed, one-size-fits-all policy onto hundreds of millions of people in the United States, legislators in Congress should support the dissemination of unbiased, science-based information about appropriate opioid use. Part of the current challenge is that so much of that information is produced by the pharmaceutical industry.
The marketing of OxyContin by Purdue Pharma is a great example of how this can be a conflict of interest. Purdue flew doctors on all-expenses-paid trips to resorts around the country to “educate” them about the merits of the drug. At the same time, the Food and Drug Administration was concluding that OxyContin was not any more effective than any other drug on the market. In 2007, the manufacturer pled guilty to misrepresenting how addictive the drug was and received a significant fine.
Rather than letting pharmaceutical companies run roughshod over clinicians, doctors need education about impacts of over-prescribing, and continuing medical education (CME) requirements should focus on responsible and careful pain management and the consequences of over-prescribing opioids.
Arbitrary limits on the days of medicine a person can receive is not good policy. Nor does it help people. And isn’t that gist of the Hippocratic oath?