From USA Today:
“Pain patients left in anguish by doctors 'terrified' of
opioid addiction, despite CDC change”
New York resident Mickey Saxbury worked on a General Motors
assembly line for 25 years before sharp, throbbing back pain from an on-the-job
injury forced him to retire. A back operation failed. A device to block his
pain gradually became ineffective. The only thing that’s consistently worked,
he says, is pain medication. But a judge
overseeing his New York State Workers Compensation Board disability case
ordered that his opioids be sharply reduced. “They dropped me so far down that
I can’t even get off the couch anymore,” said Saxbury, 61, who lives near
Buffalo. Chronic pain patients such as Saxbury are becoming increasingly vocal
about what they say is a medical community that’s shutting them out. The
Centers for Disease Control and Prevention issued guidelines in 2016 to cut
back prescriptions after years of liberal opioid dispensing contributed to
addiction and overdose deaths. Those
guidelines not only influenced doctors – state regulators, health insurers and
even disability administrators also have cited these federal guidelines to
justify policies that limit pain pill prescriptions. Last month, the CDC clarified its position,
saying that the response to the opioid crisis went too far. In a New England
Journal of Medicine editorial, a panel of experts cited examples such as
inflexible thresholds on dosages, abrupt tapering and misapplication of the
guidelines for people with cancer, sickle cell disease or recovering from
surgery. Dr. Joshua Sharfstein, a former health secretary of Maryland and
health commissioner of Baltimore, said he supports how CDC's clarified
guidelines reconcile the risk of opioids with their need. "The right thing
is to follow that balance," said Sharfstein, who is now a professor and
vice dean at Johns Hopkins Bloomberg School of Public Health. The guidelines
"shouldn’t be used as a kind of cudgel to reduce appropriate
prescribing."
Chronic pain sufferers 'between a rock and a hard place'
Many chronic pain patients question whether the revised
policy will bring them relief. Saxbury
took a powerful opioid, oxycodone, to manage throbbing lower back that radiates
down his left leg. His prescription remained steady for several years: 30
milligram pills, four times each day. But
the New York State Workers Compensation Board, which oversees his case, tapped
a medical expert to review Saxbury's medical chart. The expert, Dr. Chris Grammar,
who never physically examined Saxbury, concluded he was being prescribed unsafe
levels of opioids. In his report to the
New York board, Grammar cited the state's non-acute pain medical treatment
guidelines and CDC data on overdose deaths linked to opioid prescriptions. He
added that Saxbury's pain doctor's high-dose opioid prescriptions are "no
longer supported." "This is not to be critical of his treating
physician as this approach is relatively new," Grammar wrote.
"However, in the absence of functional improvement, this patient is
undergoing extraordinary risk with little benefit." A judge agreed and
ordered Saxbury's pain medication reduced. Based on the judge's decision, Saxbury said
his doctor cut his daily pain prescription by half. He cannot muster the energy
or tolerance to do many daily activities. And his planned move to Arizona to
escape a cold climate that makes his pain worse and live near family seems more
daunting than ever. Saxbury said he has
unsuccessfully pleaded with his doctor to reconsider the pain pill reduction. "My pain-management doctor said they
cannot give me the medication because they could lose their license," Saxbury
said. "I'm between a rock and a hard place." Grammar declined to
discuss the specifics of Saxbury's case with USA TODAY. But, in general, he
said medical evidence does not support long-term opioid use for chronic pain
patients. He said pharmaceutical companies
such as OxyContin maker PurduePharma have not proved in medical studies that
long-term opioid use alleviates chronic pain. Patients who have become
dependent on opioids now feel scapegoated as more doctors scrutinize the use of
the pain medications. "With few
exceptions, the patients are innocent," Grammar said. "They're not
writing the prescriptions."
State laws created a 'chilling effect' on pain prescriptions
States have responded to the addiction crisis by passing laws
that aim to reduce opioid prescriptions. As of October 2018, 33 states have
passed laws that limit or impose requirements on opioid prescriptions,
according to the National Conference of State Legislatures. Most of these
states limited initial pain pill fills to seven days, with some states imposing
even more aggressive cutbacks that limit fills to three or five days. Last
July, Florida passed a law requiring physicians to register as chronic pain
clinics to prescribe more than three days worth of opioids. Dr. Melanie
Rosenblatt, who is a pain doctor and certified in addiction medicine, said the
law has had a "chilling effect" on prescribing. Many of her new
patients were dropped by their former physicians or "would doctor shop
until they got what they want." Federal statistics show total U.S. opioid
prescriptions have declined each year since 2012. However, that trend
accelerated since the CDC issued guidelines. Total prescribing dropped from 46
billion morphine milligram equivalents in March 2016 to 32 billion morphine
milligram equivalents in September 2018. MMEs are a measure of the amount and
potency of opioids. John Downey, a pain
doctor in Augusta, Georgia, argues that the "damage has been done"
from restrictive state laws and reluctant prescribers. Family doctors who fear disciplinary action
from medical boards have dropped chronic pain patients. Those pain patients
have crowded the lobbies of pain clinics seeking relief. Downey served a
three-year term on the Georgia Medical Board through mid-2018 and chaired the
board's pain committee. He told colleagues he was not interested in another
term because his medical practice was so busy with patients turned away by
other doctors. One Monday morning, he had 50 referrals for new patients
"just because doctors are saying they are fed up," Downey said. While
he was on the medical board, he developed a point-based worksheet for family
doctors who treated pain patients. The goal: Help doctors determine whether
pain patients are willing to complete therapy and try non-opioid therapies such
as injections, rather than only seeking pain pills. Medical board investigators
who see patients taking the same prescription every month might see signs of
abusive prescribing or a "pill mill," said Downey. But he said such
patients often are able to maintain regular activities such as working,
spending time with family or going to church. "From a pain perspective,
that is a well-managed patient,"
Downey said. "They are stable."
Doctors are 'terrified of addiction'
Sharfstein, the former health secretary of Maryland, said
"there's been a big whiplash" as doctors react to the opioid epidemic
which was fueled by years of permissive prescribing. "Doctors
were told they should treat pain as much as possible and now might be hearing
the message they they could get in trouble for any opioids," he said. Sharfstein
and his wife, Dr. Yngvild Olsen, an addiction medicine physician, wrote the
book The Opioid Epidemic: What Everyone Needs to Know. In it, they argue that
doctors need to be trained to detect and treat addiction. Most medical
residency programs don't teach how to care for patients who misuse
substances.
An epidemic and its response:
Doctors are "terrified of addiction and need to
understand it and treat it," said Sharfstein. Garrett Greene, 27, was dropped as a patient
by his pain management doctor last month. He said the doctor told him he wasn't
comfortable seeing a cystic fibrosis patient. Greene said he was taking about a 90 milligram
dose of the opiod Percocet every day to control pain since he had surgery seven
years ago after his left lung collapsed twice. He's had many other surgeries
and blood clots. "I spent the better part of my twenties cooped up in the
hospital watching firsthand how this monster of a disease can rear its ugly
head," said Greene. Late last
month, Greene went through what he calls "a horrific detox" while he
was "losing my mind" trying to find a new pain doctor. When he found
Rosenblatt, she switched him to buprenorphine, which is also an opiate but one
that is used to help wean people off heroin and other opioids. Percocet, said
Greene, wasn't good for his lungs long term and could suppress his
breathing. Rosenblatt finds she often has to change new
clients to longer-acting opioids, as well as combinations of physical therapy,
antidepressants, muscle relaxants and therapy to help improve sleep. "Most of the time it works out really
well and there is a silver lining in many cases because people get the
appropriate specialist," said Rosenblatt. "For other people, not so
much, because they go through crazy withdrawal after doctors just cut them off,
go to jail or retire with no exit plan." Former Food and Drug Administration
Commissioner Dr. Scott Gottlieb said regulators “arguably had to play catch up”
with the opioid crisis, which he calls the “biggest public health crisis in
modern history.” Regulators “had to take dramatic action to intervene,” he
said. “It was inevitable there were going to be public health consequences at
the margins.” As for doctors, they have been “overshooting in both directions”
– first over- and now often under-prescribing. “You are seeing doctors too
reluctant” to prescribe opioid painkillers now, said Gottlieb, now a resident
fellow at the American Enterprise Institute. “It was inevitable they were going
to land there."
^ This is a sad side-effect of years-long hysteria from
politicians and those in the medical field. Rather than fight the actual cause
and problem of the opioid crisis they decided to create generalized rules and
laws to stop everyone (including the sick and dying) from getting pain
medicines. The fact that doctors would turn away sick patients is just plain
disgusting. I’m glad that the sick, disabled and the dying are now making
themselves heard and that others are finally starting to listen. Hopefully the
lawmakers and politicians will stop making generic generalized laws that only
seem to punish and hurt those that need pain medicine to do basic everyday
things (and do little to nothing to the addicts) and that the doctors and
everyone else in the medical field will stop being scared and see treating the
sick and those in pain as their job (since it literally is.) ^
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