Changes to Ohio laws endanger patients’ access to opioids
Opioid pain medications can lead to addiction, but they’re also the most effective drugs for some patients. State and federal guidelines have been crafted to guide doctors.
Bob remembers the exact date he hurt his back: June 11, 2005. He picked up a scrap item at work and gave it a toss.
Pop.
Bob ruptured a disk and herniated two others. A decade and three surgeries later, he takes five different medications daily to manage his pain, including two opioids, methadone and oxycodone.
Bob has tried other medications and therapies, including an implant that is supposed to block pain signals from reaching his brain, but opioids work best, he said.
They dull his back pain enough for him to run errands and take care of his family. But he can’t work, and he can’t play softball, basketball or golf, sports he enjoyed before his injury. His back aches most on cold and rainy days.
Bob plans his life around monthly trips to his pain specialist in Summit County and takes random drug tests.
“I do not like putting poison in my body every day,” Bob said. “And that’s what this is. It’s not good for anything but the pain. But without it, I don’t know what I would do.“
Bob is in his 60s and lives in Perry Township. He is one of the estimated 25.3 million adults in the United States who suffer chronic pain.
Bob agreed to speak to The Repository on the condition his last name wouldn’t be used. He fears becoming a target of pill thieves, he said.
He also fears that growing concern over the addictive effects of opioids and their link to heroin use could someday mean he can’t get his medicine. Under current restrictions, if he loses his pills, he can’t get more until the following month.
“It’s a horrible way to live,” he said of his daily pill regimen, “but it’s either live like that or lay in there and writhe around in the bed in pain all day.”
Cutting back
No one is planning an outright ban on prescription opioids, a class of drugs that includes familiar pain relievers like Vicodin, OxyContin and Percocet. Doctors, government regulators and addiction specialists agree that opioids can provide legitimate and effective pain treatment for some patients.
But after years of doctors freely prescribing opioids, Ohio has steadily made them harder to get as part of the state’s strategy to combat opioid and heroin addiction.
The state requires doctors to check a state database before prescribing opioids, and since 2012 has written guidelines to encourage doctors to use alternative pain treatments and to better monitor patients who take opioids.
The reforms have taken about one opioid dose in 10 out of circulation since 2012.
Some doctors stopped prescribing opioids altogether because of the stricter regulation, which leaves their patients to look elsewhere for treatment. And overlapping state and federal guidelines have created a contradictory patchwork of standards for doctors and patients alike.
Prescription opioids carry a significant risk of addiction and death. Consider:
• Almost 19,000 people in the U.S. died from overdoses of opioid pain relievers in 2014, more than five times the number in 2001, according to the National Institute on Drug Abuse.
• 4.3 million people ages 12 or older reported non-medical use of prescription pain relievers in the 2014 National Survey on Drug Use and Health.
• 4 out of 5 heroin users started by abusing opioid medications, according to “JAMA Psychiatry.”
• All opioids, including prescription drugs and heroin, killed 2,000 people in Ohio in 2014, according to the Ohio Department of Health.
Tighter regulation
Gov. John Kasich shut down so-called “pill mills” — doctors who inappropriately prescribed opioids — in 2011 by signing a law requiring licenses for pain-management clinics.
The following year, the Governor’s Cabinet Opiate Action Team rolled out prescribing guidelines for emergency rooms, such as limiting opioids to three-day prescriptions. Guidelines for treating chronic pain, including dosage thresholds, followed a year later.
“What we’ve learned is it’s effective,” said Andrea Boxill, deputy director of the Opiate Action Team. “We’ve certainly seen a decrease in the number of pills that have been prescribed, at least according to the Board of Pharmacy data.”
From 2012 to 2015, the amount of opioids dispensed to Ohio patients dropped 11.6 percent, to 701 million doses, according to Board of Pharmacy.
In Stark County, the number of doses dispensed dropped from a peak of 27.7 million in 2013 to 25.4 million in 2015.
Earlier this year, the federal Centers for Disease Control and Prevention and the state’s Opiate Action Team each released additional prescription guidelines. The CDC guidelines address chronic pain. The state guidelines address the treatment of acute pain.
Both guidelines urge doctors to use non-opioid treatments when possible, to use the lowest dosage possible when prescribing opioids, to develop a strategy to end opioid treatment, to monitor patients and to check their prescription histories before giving them opioids.
How did we get here?
“This is my opinion, we’ve created this mess because we’ve so liberally given away narcotics for things we traditionally wouldn’t have,” said Dr. Paul D. Hrics.
Hrics is chairman of Canton Aultman Emergency Physicians. Multiple times a week, he and other doctors treat overdose patients in Aultman Hospital’s emergency department.
At one time, narcotic painkillers were generally reserved for cancer patients or patients who were in end-of-life care, Hrics said. If you sprained your ankle or had dental pain, a doctor or dentist prescribed Tylenol or ibuprofen.
But during the 1990s and early 2000s, there was a national push for doctors to better treat pain. Pain became the “fifth vital sign.”
“It had to be documented just like your heart rate, your blood pressure, your temperature,” Hrics said.
Satisfaction surveys put pressure on doctors to meet their patients’ wishes, including demands for opioid pain medication.
At the same time, new extended-release opioids, such as OxyContin, came on the market. Some of the marketing materials suggested patients would be able to use less of the new medication and that it would be less addictive, “which ended up not being true,” said Dr. Amol Soin, vice president of the State Medical Board of Ohio.
Managing pain
After years of over-prescribing opioids, doctors are cutting back, looking for alternative treatments and having tough conversations with their patients.
Dr. Stacey Hollaway said one of her partners at Stark County Medical Group in Jackson Township no longer prescribes opioids, but she still does. Hollaway is certified in internal medicine and pediatrics and sees 4,000 patients on a regular basis. About 60 percent of them are adults.
There are a lot of non-opioid medicines that can be used to treat pain; and neuromuscular therapy, massotherapy, chiropractic therapy, and acupuncture are other options, she said.
But sometimes opioids are the best treatment for a patient, such as a person who has already had back surgery or who is allergic to non-opioid pain relievers.
“Do people get addicted to it? Absolutely,” Hollaway said. “Are there people who can take it every single day and never get addicted to it? Absolutely.”
Hollaway said before she prescribes long-term opioid treatment, her patient has to sign a contract.
The patient promises to use a single pharmacy, to not get a prescription from another doctor and to submit to random drug tests to make sure they’re using the medication as prescribed and not mixing it with other drugs.
Hollaway started using the contracts after Ohio set its first prescription guidelines in 2012. She estimated she has had about 50 patients on contracts for opioid pain medicines. She’s had to revoke three of those agreements.
Pain-management contracts or agreements have become standard and are recommended by the state medical board, Soin said.
Soin graduated from Northeastern Ohio Universities College of Medicine (now Northeast Ohio Medical University) in 2002 and later trained at The Cleveland Clinic.
He sees about 140 patients a week at his Dayton-area pain-management clinic. Some of them do well on opioids, but addiction can happen to anybody.
“I think the important thing is to educate the patient so they’re aware of how dangerous these drugs really are and how there are members of society who would love to get their hands on these pills, so they have to be very careful with the medications that they have,” Soin said.
When opioids aren’t right for a patient, having government guidelines makes it easier for doctors to explain why they can’t prescribe them, the doctors said.
On the horizon
While the federal and state guidelines are similar in their intent, they differ on particulars, and that can cause confusion for doctors, Soin said.
“At some point it would be really nice to marry all of these into one document or one formal guideline we could all follow nationally,” Soin said.
Doctors, pharmacists, and patients can expect more prescription drug regulation in the future.
Kasich’s administration wants to cap the supply of opioid pills a patient can get at 90 days, and prescriptions that haven’t been used in 30 days would be invalid.
To cut down on drug theft, the Board of Pharmacy wants to register the 42,000 pharmacy technicians in the state. It also wants to license doctors, dentists, and veterinarians who store and dispense controlled substances.
The media and politicians are paying more attention to opioid addiction, but good intentions can lead to burdensome regulations, Soin said. Time will tell how effective these reforms will be.
“That’s going to be part of the learning process over the next three to four years,” Soin said. “We’ll probably overcorrect and then hopefully fix what needs to be fixed.”
Hrics said he expects to be busier in the ER as the supply of prescription opioids tightens even further.
“Near term, I think we’re going to see a lot more people overdosing because they’re going to turn to heroin,” he said.
Meanwhile, Bob and other pain patients will fight their daily battles. Right now, his pill regimen is working. But if there was something he could do to get off opioids for good, he would, even if it meant losing a limb, he said.
“You find your new normal and you learn how to live with it,” Bob said. “… I am going to be in pain management, probably for the rest of my life.”
Filed under: General Problems
Mother of god! We can expect more regulations!? Okay, well, how about we slow down a bit and apply some real science and facts to the discussion?
The idea that people who have greatly benefitted from high dose opioid therapy could be left under the bus is sickening to me. And what about future pain patients? What about the ones that are ultra fast metabolizers and who are currently free from chronic pain but end up in need some day? What is going to come of them?
We are getting “painfully” close to an all out ban on opioids. Maybe not officially but certainly most doctors have already gone that route. I am dismayed how every day I sign into FB and read yet another story of a legitimate patient who’d been functioning, stable, and who hadn’t broken any rules being ripped off their opioid medications.
I agree that the 5th vital sign was ridiculous and lead too many doctors to quickly prescribe for fear of being sued for malpractice.
But what about taking some responsibility? Just because doctors were told to start addressing their patient’s complaints of pain didn’t mean they were expected to go overboard! Tell me, how is that well educated people who were able to go through medical school suddenly began to be unable to think for theirselves?
And now these patients whose brains will NEVER be the same and will never respond to low doses are being left behind for some hypothetical greater good!
What REALLY kills me is the idea that the vast majority of doctors fell for the used car salesman pitch from pharmaceutical reps that claimed they made a SUPER SAFE opioid pill! Like OMG! Freaking come on! Please, tell me doctors never really believed some magic coating was going to make an opioid pill non addictive and safe!
I do not believe the 5th vital sign was ever intended to give doctors the go ahead to prescribe strong narcotics in copious amounts! It was intended to bring pain to the attention of physicians that would otherwise ignore it. And let’s be honest, pain IS a vital sign of one’s health, wellbeing, and can also help point to a diagnosis.
As an active kid (tomboy, I had 2 older brothers), I sprianed, pulled, fractured, broke and hurt myself several times. At no point did a doctor ever suggest I take anything more than an Ibuprofen. And by the way it was available by prescription only for a dang good reason but that’s a topic for another day.
The idea or fact, that doctors came to prescribe strong narcotics for sprains, minor fractures and other nominal injuries that historically people had lived through with ice, heat, rest, and Tylenol blows my mind. But, still this fact alone is not responsible for the escalation in drug abuse, addiction, or overdoses.
A much more complex instigator came into play. Heroin. It flooded our streets. It became so ubiquitous that the price dropped drastically. This may have very well been the primary instigating factor for the increase in use.
Now, we know that addiction is a biological condition that’s compounded by sociological circumstances such as poverty.
Our country faced and hasn’t entirely recovered from a “Great Recession”. Hasn’t anyone thought about its impact on the mental health of people? It seems to me to be NO coincidence that as people suffered from job loss, losing their homes, divorce, depression, and all this on the heals of 911 that drug abuse became far more common in our society.
If we want to FIX the crisis we MUST allow people to earn a life sustaining wage for an honest day’s work. It shouldn’t matter if someone washes out garbage cans or what they do. If they go to work they deserve to be able to own a reliable car, to pay rent, to buy food and clothing, they deserve to go out to dinner and a movie and to have a few nice things above the basics.
When we lift people up and allow them to live with dignity we spare them the downfalls of depression and all it entails… such as escaping via alcohol and drugs.
I also believe that forcing disabled people to live on $700 a month without rent assitance, or fuel assistance, and many other things is morally bankrupt. Just because someone is not able to provide for theirselves doesn’t justify forcing a marginalized life on them.
Our country is sick. That’s a fact. But prohibition is not going to resolve a single thing. The stats are in and addicts are still overdosing, addicts are still seeking out drugs, suicide rates have outnumbered overdoses, most pain patients have a suicide plan in place, pain patients have left college, left their jobs, families have been torn apart, good people that had been functioning are now bound to their beds and some so much so they now have bed sores.
Honestly, where exactly is this entire PROPaganda campaign going? It appears to me that it’s a means of culling the herd and to allow those in power who are causing hype and fear among policy makers to line their pockets off the growing number of people who are needlessly suffering.
Sorry to ramble on but I am so dang tired of all this BS. When will the VOICE of the CP community be heard?
With 28 out of 30 inpatient in mental wards for forced stoppage of their MEDICINES,, klondyne is getting rich,,,DR.government is MAKING PAIN MANAGEMENT expensive,,,for 10 years,, 1nce a year,,250 bucks,,low cost to my insurance company,,,nowwww..dr.government makes insurance companies pay out 30,000,,for inpatient mentalfacility,,,plus 3 visits a year,,or every month at 300.00 for visit,,1 to 3,000 for pee in this cup,,,,,,Obviously if there were less o.d. in 2001,,,then their are now,,,,,their delusuion of ,”reefer madness,” against a inanimate object,,a pills fault is NOT WQRKING…. if they actually listen’d to us,,,,this would of never happen’d,,and dr.goverment prescription of torture and genocide for the medically ill would of never happen’d,,,,maryw
FYI Mary…the rehab center my friend was in was not owned by Kolondy. We don’t have any of his in my state THANK GOD!!!
How do u know???I mean,,,does he hold stock in all rehabs???or is it a stock holder from a different member of PROP??just sayen and asking?maryw
As Chronic Pain Sufferers we must flood their offices with story’s like mine and do it over and over and over, it’s always The Squeakiest Wheel Gets The Grease! Unrelieved pain can result in a patient limiting the movement of the thoracic and abdominal muscles in a bid to reduce pain. This may cause some degree of respiratory dysfunction with secretions and sputum being retained because of a reluctance to cough. Atelectasis and pneumonia may follow . 13 years of Chronic Pain has caused my heart to weaken to the point I had to have a upgrade from a pacemaker to a defibrillator this pulmonary dysfunction, caused by painful excursion of the diaphragmatic muscles of the chest wall, is also associated with a reduction in vital lung capacity, increased inspiratory and expiratory pressures and reduced alveolar ventilation. The resulting hypoxia can cause cardiac complications, disorientation and confusion and delayed wound healing ! And this is what The Lying Ass Federals want for us not to know ! Therefor they really want for us to commit suicide or cause whatever more illnesses to us that will shut us up and what they have intentionally done to us is convince the idiot heartless powers that be that all Chronic Pain Sufferers are addicts or junkies , that’s how stupid they are.
Notice how even the doctors now no longer differentiate between the physical dependence which is expected and addiction which is the psychological dependence that has nothing to do with the legitimate use.of the medication..it’s.ALL addiction!!