The Government's Medical Meddling Hurts Pain Patients


The Associated Press reports that "sales of the nation's two most popular prescription painkillers [hydrocodone and oxycodone] have exploded" during the last decade, "worrying experts who say the push to relieve patients' suffering is spawning an addiction epidemic." A.P. acknowledges that "the increase is partly due to the aging U.S. population with pain issues and a greater willingness by doctors to treat pain"—a positive development, given how scandalously inadequate the medical response to pain was when the upward trend in painkiller prescriptions began. But the general thrust of the piece is that doctors, once execessively stingy with opioids, are now excessively generous, and therefore something needs to be done. The problem is that all the likely government responses will tend to make it harder for patients with severe chronic pain to get the relief they need.

Washington state, for example, has responded to the perception that doctors are overprescribing opioids by establishing an arbitrary threshold beyond which pain patients can no longer receive treatment from their primary physicians. Doctors with patients who are taking "any opioid equivalent in strength to a daily dose of 120 milligrams of morphine," The New York Times reports, must refer them "for evaluation by a pain specialist if their underlying condition is not improving." The results have been predictable:

Even before the new provisions took effect, some doctors stopped treating pain patients, and more have followed suit. Christine Link, 50, said that several doctors had refused to refill the prescription for painkillers she had taken for years for a degenerative joint disease.

"I am suffering, and I know I am not the only one," she said….

The state law has transformed the clinic at the University of Washington into a pain treatment center of last resort—and Dr. [Jane] Ballantyne, the pain expert, into an appeals judge of sorts because she sees patients referred for evaluation under the law. On a recent day, she was seeing a stream of castoff patients, including Ms. Link, who sat hunched in a wheelchair, suffering from a degenerative joint disease.

"They all said that I can't treat you, you need to see a specialist," Ms. Link said of her other doctors.

The Times illustrates the impulse behind Washington's law with an anecdote about a patient who "was taking dosages so high that another doctor who examined her was shocked. 'She said, "I don't want you to die,"' [the patient] recalled." Yet tolerance to opiods' respiration-suppressing effects develops along with tolerance to their analgesic effects, so chronic pain patients who use such drugs every day for years can safely take doses that would kill a novice. It is impossible to say in advance what dose is appropriate for any given patient, let alone for patients generally.

Rep. Mary Bono Mack (R-Calif.) is pushing similar medical meddling at the federal level. Her Stop Oxy Abuse Act would decree that oxycodone should be used only for "severe" pain, as opposed to "moderate-to-severe" pain, as the Food and Drug Administration's current guidelines say. Like Washington's dose limit, this restriction arbitrarily overrides the medical judgment of individual doctors, who may find that oxycodone is superior to the alternatives for particular patients with moderate pain. Bono Mack's Ryan Creedon Act would require that doctors "obtain training or certification on addiction to and abuse of controlled substances and appropriate and safe use of controlled substances" before they can legally prescribe not only opioids but any scheduled drug, with the standards for the training to be set "by the Secretary of Health and Human Services in consultation with the Attorney General." This requirement would encourage doctors to be suspicious of patients seeking pain treatment or to simply stop prescribing opioids altogether (especially if the bill is narrowed so that it applies only to opioids or only to Schedule II drugs, as seems likely). While reducing access to these drugs may inconvenience a few addicts, pushing them into (or back into) the black market, it will also force patients like Christine Link to suffer needlessly. 

The Ryan Creedon Act is named after a 21-year-old from Bono Mack's district who died in 2009 from an overdose of OxyContin he obtained by scamming doctors. Attempts to separate people like Ryan Creedon from the drugs they want inevitably hurt legitimate patients because pain cannot be objectively verified. Doctors can do physical examinations and consider a patient's medical history, but at a certain point they have to decide whether to trust him. A mission to help patients like Christine Link points in one direction, while a mission to save addicts such as Ryan Creedon from their own recklessness points in another.

[Thanks to Virginia Postrel for the Desert Sun link.]