Regulating Opioids: Chronic Pain Patients Caught in the Crossfire

Posted by Emerald Coast Medical Association on Jun 15, 2018 10:08:45 AM

As we all know, opioid use has skyrocketed in the United States, increasing by 300 percent from 1997 to 2010. The Centers for Disease Control and Prevention released an in depth-analysis in March showing that drug overdoses killed 63,632 Americans in 2016. Nearly two-thirds of those deaths involved a prescription or illicit opioid.

Efforts to combat the rising tide of addiction have resulted in a flurry of new insurance company policies and state laws setting limits on opioid prescribing. States have also been tracking opioid prescriptions more closely through electronic databases and requiring doctors to check the databases for signs of “doctor shopping” or misuse before giving a patient opioids. This has seen the number of people newly prescribed opioid pain medicine decline by 7.8 percent over the course of 2017, after rising by less than 1 percent the previous year.

According to the report, prescription opioid volumes peaked in 2011 at the equivalent of 240 billion milligrams of morphine, declining by 29 percent to 171 billion in 2017. Still, that was enough for every American adult to have 52 pills, a fivefold higher level than in 1992.

The drop is good news for policymakers. However, reducing opioids for patients who have been prescribed the medications for many years can be challenging for physicians and patients alike. As the crisis has escalated, those who suffer from chronic pain and take opioid-based painkillers are feeling pressure from these new policies that limit prescriptions, as are the doctors who care for them.

For chronic pain patients who have been on a high dose of opioid-based medication, lowering that dose or coming off the medication entirely, either by personal choice or because doctors are limited in what they can prescribe, can be extremely painful. The body becomes dependent, and when the substance is not introduced as expected, the brain begins to send pain signals to the body in hopes of getting the opiates in response. When they are not forthcoming, the pain messages grow more intense. The body begins to go through withdrawal, a physically demanding process that adds to the chronic pain the patient is already living with.

At the same time, patients and providers have found that when pain patients are prescribed less addictive treatments, those prescriptions are sometimes denied by the insurer. Seeking out alternatives is often frowned upon by doctors, though they have been at least anecdotally shown to help many pain sufferers. Instead, the patients are being approved to try more addictive medications like oxycodone first. As doctors and insurers pull in different directions, patients suffer.

Dave Cole, who has had chronic pain for more than 15 years stemming from diabetic neuropathy, knows what it’s like to struggle to gain access to non-opioid medication. Cole's pain doctor legally had to cut back on his opioid dose. During that time, there were eight months when his new insurer wouldn't approve Lyrica. Cole had been on the drug, which is used to treat nerve and muscle pain, for a few years before. During those months, Cole says he often felt suicidal and lived in a state of ongoing pain.

"I lived in constant fear of going to the doctor," Cole said, explaining that he was worried his dosage would be cut back further. He turned to alternative treatments, such as infrared light therapy, yoga, acupuncture, and cannabidiol oil, which had varying degrees of success in helping him survive. Since these are not covered by most insurance plans though, it can get expensive, especially while living on $1,600 a month.

He once took as much as 350 milligrams of prescription painkillers a day. Now his doctors are working to cut him down to 120 milligrams. So far he's managed to bring it down to 140 milligrams, but the restriction means he can't get out of bed as much; it means he can't see his grandkids or children as often because of the pain. He says used to be able to leave his bed and move around 40% of the day. Now, with the reductions in his dose, it's closer to 10%.

Because prescription drugs have been integral to the opioid crisis, restrictions around the drugs have been part of the solution that policymakers and the healthcare industry have turned to because it’s easier to regulate. Instead of cracking down on patients who are following doctors orders and reciting needed care, some physicians feel the focus should turn to illegal opioids, including heroin and fentanyl, which have the deadliest consequences.

Instead of blanket policies from politicians that cap prescription limits across the board, most pain patients have a simple request: They want their relationship with their pain doctors left as it is. The hoops needed to jump through to have that relationship, like drug tests and routine checkups, are totally acceptable, the accountability is necessary, but, as Cole says "The CDC shouldn't be telling my doctor how much I need.”

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Topics: Opioids

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