I have written here and here about how patients have become the civilian casualties of the misguided policies addressing the opioid (now predominantly fentanyl and heroin) crisis. The policies have dramatically reduced opioid prescribing by health care practitioners and have pressured them into rapidly tapering or cutting off their chronic pain patients from the opioids that have allowed them to function. More and more reports appear in the press about patients becoming desperate because their doctors, often fearing they may lose their livelihoods if they are seen as “outliers” by surveillance agencies, under‐treat their pain or abruptly cut them off of their pain treatment regimen.
A story in the July 23, Louisville (KY) Courier Journal illustrates the harm this is causing in Kentucky. “Doctors say the federal raids on medical clinics lead to unintended consequences — patients thrust into painful withdrawals and left vulnerable to suicide or dangerous street drugs,” states the article. Dr. Wayne Tuckerson, President of the Greater Louisville Medical Society, said, “[When investigators] go in with a sledgehammer and shut down a practice without consulting community physicians, suddenly we have patients thrown loose.” He went on to say, “Docs are very much afraid when it comes to writing pain medications…We don’t want patients to become addicted. And we don’t want to have our licenses — and therefore our livelihoods — at stake.” And if pharmacists in the area learn of a police raid or investigation of a medical practice—regardless of the outcome of that investigation—many of them refuse to fill legal prescriptions presented by patients of those practitioners.
Last week Oregon regulators announced plans for a “forced taper” of chronic pain patients in its Medicaid system. This contradicts and is much more draconian than the recommendations of the 2016 guidelines issued by the Centers for Disease Control and Prevention, which in turn have been criticized as not evidence‐based. The Oregon Health Evidence Review Commission announced:
The changes include a forced taper for all chronic pain patients on opioids (within a year), no exceptions. Opioids will be replaced with alternative treatments (cognitive behavior therapy (CBT), acupuncture, mindfulness, pain acceptance, aqua therapy, chiropractic adjustments, and treatment with non‐opioid medications, such as NSAIDS, Acetaminophen).
This proposal has sparked an outcry from patients and patient advocacy groups in Oregon. While this policy proposal only applies to Medicaid patients, they fear it will soon become the standard adopted by all third‐party payers in the state.
University of Alabama Medical School Associate Professor Stefan Kertesz, an addiction medicine specialist at the Birmingham VA Medical Center, tweeted in reaction to this proposal:
I cannot imagine a more violent rejection of the CDC Guideline on Prescribing Opioids of 2016 than the plan current before Oregon Medicaid : forced taper to 0 mg of all opioid receiving pain patients.
These policies are based on the false narrative that the overdose problem is primarily the result of doctors prescribing opioids to their patients in pain and getting them hooked. In fact, the problem has always been a product of drug prohibition—non-medical users accessing opioids on the black market. To illustrate, an often‐overlooked study published in the American Journal of Psychiatry in 2009 followed more than 27,000 OxyContin addicts entering rehab programs from 2001–2004. It found 78 percent said they never had obtained a prescription of OxyContin for any medical reason, 86 percent said they used the drug because they liked the “buzz” or “high,” and 78 percent reported prior treatment for substance abuse disorder.
There have been well‐documented cases of unscrupulous doctors teaming up with dishonest pharmacists to operate “pill mills”—gaming the third‐party payment system to receive compensation for running drug‐dealing operations. But these bad apples have largely been rolled up by law enforcement and represented an exception to the rule of how doctors treat pain. Nevertheless, these stories continue to feed the narrative.
Dr. Charles Argoff, a professor of neurology at Albany Medical College and Director of its Comprehensive Pain Center recently surveyed colleagues in a report for the medical education website Medscape.com entitled “Readers Respond: Stop Stigmatizing Opioids.” The majority of clinicians dealing with pain bemoan the hysteria driving the governments’ response to the overdose problem. One clinician emphasized, “Dependence is the rule, addiction is the exception.” Another complained about the “misinformation, distortion of evidence‐based research, political influence, and even mainstream media sensationalism‐style reporting, which together has deteriorated to such an extent that it is beyond belief…A person should review all available information that is opposing the arrogantly forgotten patient.”
Dr. Argoff concluded his survey with the following comment:
In summary, I hope these comments further epitomize and suggest how complicated opioid therapy is. But what I am struck by is how much these comments point to identifying that subset of individuals for whom these medications are successful and also outlining the risk of so many other medical treatments, both interventional and noninterventional, that we consider for our patients with chronic pain.
Meanwhile the civilian casualties mount. Dr. Thomas Kline, a physician in North Carolina, is maintaining a growing list of patients who commit suicide after being cut off from their pain medication. Expect the deaths—of patients as well as non‐medical users—to continue until policymakers come to the realization that the root cause of the problem is drug prohibition.
