Arizona's Misguided War on Opioids
Reacting to concerns about rising opioid use and abuse, Arizona's governor, Republican Doug Ducey, issued an executive order earlier this month requiring the director of the state's Medicaid program, as well as the director of the state's employee health plans, to limit the coverage of opioid prescription to a seven-day supply. There are a few exceptions allowed, such as prescriptions for children with cancer.
Physicians across the state are incensed at the order. They rightly view this as an infringement upon their autonomy, integrity, and judgment as medical professionals, and as interference by an outside party with the doctor-patient relationship. As a surgeon in private practice in Phoenix, I share in that reaction.
In fact, I recently performed an outpatient surgical procedure on a Medicaid patient. When I handed her an opioid prescription in the recovery room for her postoperative pain, I was tempted to tell her to contact the Governor's office if she is still in pain when she uses it up and needs a refill.
But this new policy is wrong on many other levels beyond the obvious one just mentioned.
Policy makers constantly implore doctors to practice "evidence-based" medicine. But this executive order is not evidence-based. Despite the fact that the Governor cited 401 deaths in Arizona due to opioid addiction last year, the National Survey on Drug Use and Health (NSDUH) reports that non-medical use of opioids peaked in 2012 and has since dropped to 2002 levels. And even taking into account the Center for Disease Control and Prevention (CDC) report that heroin use has gone up as opioid prescribing has gone down, total opioid use was still lower in 2014 than 2012.
Furthermore, the actual evidence suggests that restricting opioid prescriptions, especially to those who have developed a physical dependence, has contributed to the increase in the use of heroin, marijuana, and other illegal drugs, as patients seek to self-medicate.
And upon what evidence does the Governor arrive at the seven-day limit? Why not five-days? Why not ten?
Meanwhile, as Medicaid patients across the country face longer and longer wait times to see the diminishing number of participating medical specialists, it appears that Governor Ducey will make many of them suffer needlessly in pain while waiting.
The governor was certainly within his rights, as the ultimate CEO of the state's employees and the Medicaid program, to issue this order. But this brings to light another point: "He who pays the piper calls the tune."
The third party payer gets to decide what services, drugs, and devices it will pay for, and under what circumstances. Private third party payers enter into voluntary contracts with consumers and providers, and if a system is completely voluntary and non-coercive, then the parties to the contract have no right to complain.
But when that third party payer is inserted into the equation coercively it's completely different. The Affordable Care Act forces the public to contract with third party payers who are indirectly managed by the government. And in many cases, it places people into government-run programs like Medicaid.
Now many are calling for replacing the ACA with a single-payer government-run system—sort of "Medicaid for all." When the politicians have complete control of health care, look for more and more instances of politically driven encroachments on the practice of medicine and the patient-doctor relationship.
With "Doctor" Ducey's latest prescription for a large cohort of Arizona patients we might just seeing be the tip of the iceberg.