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Punishing Patients Won’t Reduce Opioid Deaths

A new Medicare prescription rule will aggravate undertreatment of pain.

Barbara McAneny, president of the American Medical Association, recently described a patient with metastatic prostate cancer who 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. "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 take effect on January 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 (CMS) noted that a proposed rule requiring insurer approval for prescriptions totaling 90 morphine milligram equivalents (MME) 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 (CDC) 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 AMA 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.

© Copyright 2018 by Creators Syndicate Inc.

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  • JFree||

    How is it that the US prescribes about 6x more opioids per capita than Portugal - and FAR more than every other country as well - and all I hear at Reason is whining that people should be happy to pay even more for someone else's opioids cuz they just can't get enough.

    How is it that the US consumes 99% of the world's hydrocodone? Prescribes 85% of all the world's opioids?

    How is it that every other country can fathom alternatives to opioids for pain -- but all I read on this site is corporate pharma propaganda re opioids that has been proven deceitful, false, and deadly.

    I've had enough. My response to every one of these articles now is - Let them fucking die already.

  • DajjaI||

    I kind of agree with this. I don't blame the government, I blame the people who were told about the problem and were silent. Which by now is pretty much everyone. They will just have to learn the hard way when they are denied opiates when they really need them. Nothing will change until that happens.

  • gaoxiaen||

    Yay!

  • C. S. P. Schofield||

    Is it possible that people who, in other parts of the world, die of their injuries, live in the US, but do so with chronic pain?

  • David Welker||

    Alternatives to opioids, such as non-steroidal anti-inflammatory drugs (NSAIDs) also have their problems. For example, most NSAIDs (with the exception of aspirin) have an FDA black box warning because they increase the risk of heart attack and stroke. In fact, Vioxx caused anywhere from 60,000 to more than 500,000 deaths.

    So, before you condemn opioids, you should realize that the alternatives may have even more serious problems. Especially in people with risk factors for heart disease and stroke.

    By the way, you talk about corporate propaganda. But guess who manufacturers NSAIDs? You guess it! Corporations. So, I don't think your prejudice against opioids is explained by your concerns about corporate propaganda after all.

    People should not have to live their life in unbearable pain just because YOU want to "protect" them from opioids. Oh wait. You don't want to protect them, do you. Let me quote you. "Let them fucking die already." Sure. Death is way better than opioids, right?

  • gaoxiaen||

    +1 brain

  • JFree||

    So, I don't think your prejudice against opioids is explained by your concerns about corporate propaganda after all.

    The specific lie - 1% will become dependent/abuse - is likely gonna appear in this thread by someone pretending to be a doctor (or worse - perhaps actually a doctor). That fraud is directly responsible for creating the problem that is unique here in the US. What could possibly go wrong?

  • JFree||

    In fact, Vioxx caused anywhere from 60,000 to more than 500,000 deaths.

    And there are precisely zero prescriptions for it now. Probably zero for the last decade plus. I haven't read any Reason articles saying 'the pain the pain the pain. Medicare really should reimburse for generic versions of it if there is any mfr who is willing to market it as perfectly safe and any doctor who is willing to prescribe it as perfectly safe. Why should we punish patients? The pain the pain the pain.'

  • Sedona Vortex Hunter||

    if you don't care if these people live or die, then can you at least quit interfering in their life and micromanaging what they are allowed to ingest or not ingest? I think most people would be very happy if you would just fuck off, nobody wants anything at all from you, just leave them alone,

    If you did leave them alone you would suddenly find that people were in fact no dying, which I am sure would be an incredible disappointment to you. I am sure you could find some other way to busy body your way into being an annoying prick though.

  • Berserkerscientist||

    Opioids aren't addictive (0.6% per person per year), aren't really that dangerous, are fairly easy to withdraw from, and cheap. Make them legal and people will stop dying from poisoned street opioids.

  • Sevo||

    JFree|12.19.18 @ 2:02AM|#
    "How is it that the US consumes 99% of the world's hydrocodone? Prescribes 85% of all the world's opioids?"

    How is it that JFree makes such stupid comments?
    WIH does it matter whether the rest of the world does something. You should grow a brain-cell or STFU.

  • ||

    I would put #1 down to Hydrocodone being a US-specific opioid product, other countries have other opioids that you can't get in the US easily. It used to also be prescribed in Germany, where it was invented, but they've since moved on to other stuff probably because of patent-expiration reasons and general profitability, but I'm just guessing there.

    The reason why 85% of all the world's opioids are prescribed in the US I would put down to the US being one of the wealthiest nations. It's really pretty simple. If you watch any show at all about drug trafficking on Netflix (Narcos, El Chapo, real-life documentaries, etc.) it's fascinating to see the map graphics they use to depict the drug trade. Basically all of the smuggling routes out of Colombia go to either the US, or the UK via Spain (although Colombian drugs find their way into all countries). I would hazard to guess that the reason is because those destinations are simply where there is the highest market demand coupled with the most money to spend on things like drugs. I don't reckon there's a difference in those 2 driving factors when it comes to legit vs. not-legit drugs. Just the demand is driven by pain instead of pleasure in the case of legit drugs.

    PS. I replied to you because that guy seemed like a dick, and you happened to call out the bit I was interested in replying to in his original dick comment. I find this topic to be extremely fascinating whether it's legal or illegal drugs we're talking about.

  • C. S. P. Schofield||

    The War on Drugs is a barbarism. It has been going on, to one degree or another, all my adult life, and if it has accomplished any good commensurate with the cost in lives, treasure, and liberty, I cannot identify it. So, some people game the system to gat prescriptions for opioids that they then take for recreation; so what? If cracking down on such people 'for their own good' causes ONE person with genuine chronic pain to be unable to get the relief he needs, then it isn't worth it.

    I have been reading about drug 'epidemics' for decades. They never amount to much, and burn themselves out in few years. What is constant is the expense, the loss of civil rights, and the inculcation of a 'gang busters' mentality in the police. It used to be that, unless you were shooting out of the windows, the police were expected to knock and announce and present you with a warrant before they entered your home. The Drug War was used to justify 'no knock' warrants and 'dynamic entry' raids, and once these became normal their use spread. There is no excuse for a no-knock dynamic entry raid on a VFW poker game, but it has happened. No Knock raids that get the address wrong, or are otherwise mistaken create dangerous situations in which innocent citizens are all too likely to be killed.

    This idiocy must stop. End the war ion Drugs. Legalize everything, and let the drug users ruin their own lives instead of having the State do it for them.

  • gaoxiaen||

    Yay! Great rant!

  • ||

    This is so true. Opioids literally work like that. Your opioid receptors down regulate themselves such that while you never achieve the same high as the first time, you eventually will reach the point where you are no longer interested in using drugs for the same reason as you did when you started using, i.e. to feel euphoria. It becomes about managing the withdrawal after a certain point.

    I'm convinced that the only reason drug use is even a problem for society is because it is prohibited. People who are heavy addicts can function perfectly well in society once they've reached the point that they no longer can get a nod and are just using the drug to avoid withdrawal. The only reason they currently can't is because they are forced to hustle for the prohibited drug. If they could just get a maintenance prescription legally at any pharmacy, I'm fairly convinced they wouldn't be a societal problem and most would be willing and able to work. The substances could be taxed, and everybody would win. I'm talking mainly about opioids here. I'm not so sure about meth or other stuff. Weed absolutely works like this as is being proven now that it is legal in so many places.

    It would still suck to be an addict, to be sure, but there are plenty of things you can do to yourself that suck (smoking, gambling, drinking, porn addiction) that we don't care if people do. But the prohibition on drugs hurts all of us way more than taking drugs hurts, what, 20% of us?

  • JeremyR||

    Why is a libertarian publication advocating for anything other than the abolishment of medicare? Instead of arguing it should spend more money buying drugs for poor/old people?

  • David Welker||

    Libertarianism is about giving people more freedom. So, you might disagree with a government program but still think, that just so long as the government program exists anyway, that the government program should offer more freedom.

    Why is that difficult for you to understand? If we don't live in a perfect world, we might still live in a better one that offers people more freedom.

  • gaoxiaen||

    Okay.

  • Robert||

    I favor that generally, but in this case patients are still free to pay cash for the drugs for which Medicare reimbursement is denied.

  • ThomasD||

    You do not 'give' freedom. And government, which by it's very nature must take and consume before it can return anything, certainly does not increase freedom.

    That sort of attitude is anathema to actual libertarianism.

  • perlchpr||

    I mean, fuck cancer patients, right?

  • Unicorn Abattoir||

    If it saves even one life, benevolent mother government will let people die.

  • a ab abc abcd abcde abcdef ahf||

    Fark.com is a great way to waste 5 minutes while waiting for something. But OMG farkers are idiots. Can't think past the immediate outrage, always want someone to do something, which of course means using other people's money to do what they want done, fuck property and individual independence.

    So sometimes it is even more fun to read the comments than the freaky linked articles. What astonished me the other day was a reference to a mainstream article on this so-called opioid epidemic. Normally comments run about 100:1 in favor of the linked outrage. This one was much closer to 50:50, with the usual idiots spouting off about Buck Up and Man Up and Take Tylenol. But a lot were personal anecdotes about post-surgery pain and how various prescription opioids got them through the pain and it was extremely aggravating to only get a few days prescription at a time.

    When you've lost the farkers, you've lost the game.

  • spork||

    I left that dumpster fire when Drew caved to SJW tenets for his comment policy. It used to have a much higher level of intellectual discourse, subversive topics and excellent snark. Now it is just a bunch of barely-sentient millennials nodding in agreement without much thought or information. Seems like the majority of the comments go, "I did not read the article, but here is my magical-thinking-based opinion."

    Same goes for Slashdot.

    At least we only have Hihn & company to ignore here.

  • Jury Nullification||

    Yeah, I think this sichiation will work itself out just fine. Just as soon as pharmacists realize their license is not worth dying for as a consequence of becoming the point of contact barrier for denying relief to those in severe pain.

    People in severe pain, especially the terminally ill, will either direct their anger inwardly, outwardly or both in pursuit of relief when denied.

  • Jury Nullification||

    Desperation and necessity are the mothers of retribution.

  • Unicorn Abattoir||

    Not that this needs saying, but NEVER throw out old opiates. The day may come when you need them and won't be able to get them.

    They may lose potency, but they don't turn toxic. Something is better than nothing.

  • Echospinner||

    The pendulum has swung too far and it is up to the medicals to push back. If you read these guidelines they all dissemble and caution in text. That is not always what happens in real life.

    The biggest problem with opiates is a technical breakthrough in the illegal market. They can cheaply produce and distribute fentalyl.

    That is catastrophic.

  • ||

    Fentanyl actually has a relatively high therapeutic index when used correctly, compared to heroin and even morphine. The problem with fentanyl is dumb-ass greedy low level dope dealers who are short on skill and equipment but long on greed to cut their heroin with it.

    Most low-level dealers just physically can't cut a kilo of heroin with something the size of a few grains of sand and expect it to be uniformly distributed. Higher level dealers don't need to cut their shit.

    Of course, none of this has fuck all to do with legit prescription pills like oxycodone, save for the fact that there is a flood of fentanyl laced counterfeit pills killing kids because of prohibition of the legit stuff.

  • ThomasD||

    Sullum still refuses to do any actual reporting on the apocryphal story from the AMA shill. Because even if the insurance refused to pay he still had the option of buying out of pocket, or having his physician contact the insurance.

    But hey, it's a gut wrenching story, so why risk mucking it up with facts...

  • susancol||

    Your ignorance is showing. Pharmacists can and do take a cue from insurance coverage to determine that they have no interest in risking their license by filling a prescription that an insurer has determined is not medically necessary. Make up another one.

  • Sebastian Cremmington||

    Omg, opioids aren't dangerous it is the lack of access to cheap opioids that is dangerous!! Just make opioids cheap and accessible and this "crisis" would disappear overnight. And Rush Limbaugh was taking handfuls of opioids and none of his 20 million listeners knew because opioids if anything improve work performance. Just so much stupid!

  • Truthteller1||

    Yes we want the federal government and the insurance industry to dictate what doctors can and cannot prescribe. It's just alternate reality stuff. What the fuck is wrong with us? Common sense is a rare commodity.

  • GryFalcon||

    Eliminate the controlled substances act and legalize opioids so that addicted people can obtain them to manage their addiction. But, severely limit the potency. Sell them in low doses with clear labelling regarding potency. While this seems counterintuitive, many overdoses occur because people do not have a choices or information about potency and dose in the products they obtain on the black market. If they are sold over the counter, it accomplishes several things. We no longer have a motive for "script doctors" to push opioids on patients to get them to come in over and over again. Patients like this one who are in severe pain can access medicine by buying it themselves. BUT -- since it becomes OTC, it comes out of their own pocket, like ibuprofen. Medicare patients will buy only what they need and will not hit up medicare for it, instead of milking medicare for millions upon millions for a recreational drug and then reselling it on the black market. It will be taxed, like any legitimate product, and those proceeds will go to the State which can have greater resources to cope with this epidemic. Then, legalize all forms of marijuana so that people who need to cope with pain, and don't want to become opioid addicts, have a real option.

  • Jakee308||

    This is what happens when bureaucrats get between a doctor and their patient. And it's also what happens when the government decides to take action because of a perceived problem.

    The first thing that is done is to limit the easily limited factors. This is why gun control is the go to action to take whenever a mass shooting takes place. It's not the gun that did the shooting. Banning guns will not stop a criminal from shooting people with an illegally possessed gun.

    Just as causing problems for patients who need a addictive medication will not stop overdoses or the illegal sale of pain medication.

    The reason why the focus on the prescription is because of the perception and sometimes fact that it is registered doctors who are over prescribing pain medication for various reasons.

    There are other ways to prevent this but the easy way is to make it harder for patients to be prescribed pain medication. They don't care if this causes problems for the patient if it solves or seems to solve the problem.

    To a hammer everything looks like a nail. Government is the biggest hammer there is.

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