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The problems with one-size-fits-all laws on opioid prescriptions

Politicians keep proposing overly rigid rules that harm people in pain.

(George Frey/Bloomberg News)
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Presidential hopeful Sen. Kirsten Gillibrand (D-N.Y.) is the latest politician to make the mistake of backing a one-size-fits-all effort to reduce opioid prescribing. Last month, she announced a bill, co-sponsored by Sen. Cory Gardner (R.-Colo.), aimed at addressing the overdose crisis by limiting opioid prescriptions for acute pain to seven days.

Gillibrand was promptly criticized by disability-rights advocates and chronic-pain sufferers. “It’s clearly a well-intentioned bill,” said Julia Bascom, executive director of the Autistic Self-Advocacy Network, who lives with chronic pain, “but anyone who is living this can tell you how quickly it can fall apart in practice.” Others were harsher: “This is NOT the solution,” read one early response on Twitter. “This is a clear doctor-to-patient issue. … What are you guys thinking?”

Taken aback by the criticism, Gillibrand responded on Medium. “I hear you,” she wrote, assuring readers she wanted to make sure health-care decisions remain “between doctors and patients” (although the bill was designed precisely to tie doctor’s hands).

The Gillibrand-Gardner bill is aimed solely at prescriptions for acute pain — such as pain following surgery — and exempts chronic-pain prescriptions from regulation (as well as prescriptions related to cancer treatment and end-of-life palliative care). But patients and activists know that regulation in one area often has unwelcome spillover effects. And the line between chronic and acute pain is not cut and dried: Pain that is symptomatic of chronic illness is often first diagnosed as acute pain.

I’ve seen the opioid epidemic as a cop. Living it as a patient has been even worse.

All of which means tackling the overdose crisis with formulaic solutions may do more harm than good.

These two politicians are far from the only ones to propose strict limits on how doctors may prescribe opioids. Sen. Rob Portman (R-Ohio) recently announced he would reintroduce a bill with even shorter limits for acute-pain prescriptions: three days. At least 32 states have enacted limits on access to opioid pain medication, as have numerous private health insurers and several major pharmacy chains.

Regulation of opioid prescriptions has been accelerating since the Centers for Disease Control and Prevention issued guidelines on opioid prescribing in 2016. The guidelines were largely about the treatment of chronic pain but included some observations about acute pain. The CDC suggested acute pain will rarely require prescriptions beyond three to seven days and cautioned doctors about prescribing doses higher than the equivalent of 90 milligrams of morphine daily.

But those guidelines were voluntary and allow for provider discretion if a patient needs longer supplies or higher doses. Policymakers, in contrast, have translated those recommendations into absolute limits.

We have already seen the result of too rigidly applying the guideline in the case of chronic pain sufferers, many of whom have taken opioids for decades. A December 2018 report by Human Rights Watch found that doctors were abruptly reducing or eliminating chronic pain patients’ opioid medication without their consent, even when they believed patients benefited from the medication and were not misusing it.

Maria Higginbotham of Wauna, Wash., told Human Rights Watch she had undergone 12 operations to prevent the collapse of her spine. These surgeries left her with a painful condition called adhesive arachnoiditis. She was responding well to opioids, yet Higginbotham’s provider was in the process of cutting her dose by 70 percent, fearful he could be held liable for prescribing over the CDC-recommended dose. As a result, “I cannot hold my 15-month-old grandson,” Higginbotham said. “I cannot hold my beloved dogs; I can’t bend over to touch them.” With her medication reduced, she needs help just to go to the toilet.

Higginbotham’s story and that of others in the Human Rights Watch report raises serious questions about what is happening to the estimated 13 million chronic-pain patients who are on opioids long-term — a concern echoed in a letter by experts who called forced tapering of these drugs a “large-scale humanitarian issue.”

Building on this concern, another group of 300 physicians, including three former drug “czars,” released a letter last month warning of the dangers of nonconsensual dose reductions and appealing to the CDC to clarify that their guidelines were not intended as unbending rules. Even in the absence of state or federal laws, they observed, doctors, insurers and pharmacies were treating the guidelines as de facto limits.

The Gillibrand-Gardner and Portman bills go even further in regulating acute pain than the existing state laws, which often allow providers to override legal limits case by case. Were those federal bills to become law, patients would have to return to their physician if they needed more than a three- or seven-day supply of medication following a surgery or injury — no easy task for someone who has just had a hip or knee replacement (or who would be financially burdened by additional co-pays).

Even cancer patients, whom lawmakers invariably exempt from their rules, are being punished. At a recent nationwide American Medical Association meeting, outgoing president Barbara L. McAneny told a harrowing anecdote: After a pharmacist denied a prescription she had written for one of her cancer patients, incorrectly suspecting the patient was a drug seeker, the patient attempted suicide.

How to stop the opioid crisis

The general clampdown on prescribing disproportionately affects women, who suffer more often than men from chronic pain, and people of color, whose pain, studies have shown, is taken less seriously by doctors and nurses.

Gillibrand and others are right to point out the dangers of leftover opioids in medicine cabinets across the United States; they are easily diverted or misused. Most people who misuse prescription opioids did not receive them while under a doctor’s care; they stole, borrowed or bought medication that had been prescribed to others.

But opioids remain essential medication for millions of people in the United States who are in pain and who use them appropriately as prescribed. And while overprescription may remain a problem in some cases, data suggests it is far less of a problem than it used to be. The number of opioid prescriptions dispensed by pharmacies is at a 15-year low, for example.

Today, overdose deaths are driven largely by illicit drugs such as fentanyl and heroin. And the deaths related to prescription opioids almost always involve multiple other substances — such as alcohol or illicit drugs — used in combination. We clearly need to look beyond prescription cutbacks if we want to solve this crisis.

It is indisputable that our response to the opioid crisis, viewed broadly, remains inadequate. Naloxone, which rapidly reverses overdose deaths, is not as widely used as it should be, in part because prices keep rising. Our laws unduly limit access to treatments such as methadone or buprenorphine, which relieve cravings and are considered among the best treatments for opioid-use disorder, cutting death rates by half.

We need to address the crisis comprehensively. The CARE Act, sponsored by Sen. Elizabeth Warren (D-Mass.) and Rep. Elijah E. Cummings (D-Md.), would help by unleashing $100 billion over 10 years for addiction treatment, harm-reduction services and prevention programs.

But we also need to treat pain. Fifty million Americans experience daily, chronic pain, and nearly 20 million have pain so severe it is effectively disabling. Politicians need to take that pain as seriously as they take addiction and overdoses. Pain and addiction are two of America’s biggest public health problems. Overly simplistic policies, including mandatory prescription caps, will do little at this juncture to stem the overdose crisis, and they risk doing serious harm.