A bill sponsored by Sen. Rob Portman (R-Ohio) would impose a nationwide limit of three days on initial prescriptions of opioids for acute pain. "People are dying around the country every single day because patients are being prescribed too many opioid pills at one time," Portman's spokesman tells The Daily Beast's Jackie Kucinich. "A three-day limit is common sense, based on CDC guidelines, and Senator Portman is going to stand up and fight for what is right."
In reality, Portman is fighting for what is wrong, both factually and morally, because a three-day limit is not common sense, it is not based on CDC guidelines, and it is not sound medicine. As Jeffrey Singer notes on the Cato Institute's blog, the American Medical Association for once is taking the right position on federal meddling with health care by opposing Portman's bill. In a statement quoted by Kucinich, the doctors' organization says:
A strict three-day limit ignores the admonition from the CDC guideline that "Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient's clinical situation, functioning, and life context," misstates the actual recommendation of the CDC, and applies limits to clinical situations to which they were not intended to be applied. Limits and one-size-fits-all approaches will not end this epidemic.
Here is what the CDC's guidelines say about opioid prescriptions for acute pain:
When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
Contrary to what Portman seems to think, that is not an endorsement of a mandatory three-day limit. In fact, saying that three or fewer days "will often be sufficient" implies that longer prescriptions usually are necessary.
Even if Portman correctly understood the CDC's advice, he would be mistaken to think it is supposed to be a hard-and-fast rule, let alone a rule enforced under the threat of taking away a physician's prescription privileges, as Portman's bill would do. As the AMA notes, the CDC emphasizes that care should be tailored to each patient:
Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient's clinical situation, functioning, and life context. The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations. Clinicians should consider the circumstances and unique needs of each patient when providing care.
The CDC's guidelines nevertheless have been widely misinterpreted as calling for strict limits, especially on daily doses, which has led to serious problems for people suffering from severe chronic pain. "When health care providers read and interpret these guidelines, they understand them to be informational, nonbinding, and inconclusive," writes Singer, a Phoenix surgeon, Cato senior fellow, and Reason contributor. "But that's not how politicians 'do science.'"
Unfortunately, the evidence suggests that many health care providers have joined politicians in misinterpreting the CDC guidelines. Otherwise chronic pain patients who have been doing well on opioids for years would not suddenly find their doses arbitrarily slashed, leaving them bedridden and in some cases suicidal. The CDC itself bears a lot of responsibility for those outcomes because the dose numbers it settled on do not have a firm scientific basis but are implicitly presented as the outer limits of sound medicine.
When it comes to acute pain treatment, however, Portman is clearly misreading what the CDC said, and he is far from alone in doing so. Since the guidelines were published in March 2016, legislators in 18 states have limited the length of initial opioid prescriptions for acute pain, according to a tally by the National Conference of State Legislatures. Seven days is the most common limit. Only two states, Florida and Kentucky, have imposed a statutory three-day limit for adult patients. Kentucky makes exceptions for major surgery or trauma, while Florida allows seven-day prescriptions "if medically necessary based on provider professional judgment." Portman's bill has no such exceptions.
Even seven days will be too short for many postsurgical patients, which could lead to more refills and paradoxically increase the number of pills dispensed. A three-day limit with no exceptions is clearly extreme and medically unjustified. Yet The Daily Beast's Kucinich portrays the AMA's opposition as nothing but self-interested special pleading. She quotes one senator's complaint that his colleagues are "too scared to take on the AMA," notes the group's spending on lobbying, and says "the AMA opposition to proposals like limiting prescriptions…to three-day supplies" has "confused and infuriated advocates." The problem, I think, is that they were already confused.