“The moral test of a government is how it treats those who are at the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadow of life, the sick and the needy, and the handicapped.” – Hubert Humphrey
passionate pachyderms
Pharmacist Steve steve@steveariens.com 502.938.2414
The face of the nation’s opioid epidemic increasingly is gray and wrinkled.
But that face often is overlooked in a crisis that frequently focuses on the young.
Consider this: While opioid abuse declined in younger groups between 2002 and 2014, even sharply among those 18 to 25 years old, the epidemic almost doubled among Americans over age 50, according to the Substance Abuse and Mental Health Services Administration.
Because of information like that, the Senate Special Committee on Aging convened a hearing Wednesday on opioid misuse by the elderly.
“Older Americans are among those unseen in this epidemic,” said Sen. Robert P. Casey Jr. (Pa.), the top Democrat on the panel. “In 2016, one in three people with a Medicare prescription drug plan received an opioid prescription. This puts baby boomers and our oldest generation at great risk.”
Unwittingly, Medicare compounds the epidemic by funding needed opioids that can be abused, but, generally, not funding the care and medicines needed to fight opioid addiction.
“Overall, one in three older Americans with Medicare drug coverage are prescribed opioid painkillers. However, while Medicare pays for opioid painkillers, Medicare does not pay for drug and alcohol treatment in most instances, nor does it pay for all of the medications that are used to help people in the treatment and recovery process,” William B. Stauffer, executive director of the Pennsylvania Recovery Organizations Alliance, in Harrisburg, Pa., said at the hearing. “Methadone, specifically, is a medication that is not covered by Medicare to treat opioid use conditions.”
Offering scary statistics and practices involving older folks, Gary Cantrell, a deputy inspector general at the Department of Health and Human Services, said “our nation is in the midst of an unprecedented opioid epidemic.”
He focused on Medicare Part D beneficiaries. Part D is the prescription drug section of Medicare, the government health insurance program covering older people. About a half-million Part D recipients “received high amounts of opioids” in 2016, Cantrell said. Almost 20 percent of that group are at “serious risk of opioid misuse or overdose,” he warned, placing the high risk in two categories — those receiving “extreme amounts of opioids” and some “who appeared to be ‘doctor shopping.’ ”
Doctor shoppers “each received high amounts of opioids and had four or more prescribers and four or more pharmacies for opioids,” Cantrell explained. “While some of these beneficiaries may not have been doctor shopping, receiving opioids from multiple prescribers and multiple pharmacies may still pose dangers from lack of coordinated care. Typically, beneficiaries who receive opioids have just one prescriber and one pharmacy.”
Many elderly get hooked on opiates through prescriptions, rather than street drugs like heroin.
“Older adults are at high risk for medication misuse due to conditions like pain, sleep disorders/insomnia, and anxiety that commonly occur in this population,” said Stauffer, who is in long-term recovery. “They are more likely to receive prescriptions for psychoactive medications with misuse potential, such as opioid analgesics for pain and central nervous system depressants like benzodiazepines for sleep disorders and anxiety. One study found that up to 11 percent of women older than age 60 misuse prescription medications. The combination of alcohol and medication misuse has been estimated to affect up to 19 percent of older Americans.”
Sixty-one-year-old Denise Holden is in long-term recovery, too, but she became addicted as a young woman seeking a heroin high. She’s been in recovery for almost 25 years, after first using drugs when she was 19. She got clean, then relapsed, as is common, then got clean again. Staying that way, even after decades clean, is not easy.
“I recently had back surgery,” the West Melbourne, Fla., resident said in an interview. “I had a spinal fusion and so I had been taking opiates for a period of time. You know, the older we get the more aches and pains we get. … We injure ourselves, we have surgeries. So, for people in recovery it’s a slippery slope because when you reintroduce that opiate to your system, your mind starts playing all kinds of tricks on you — ‘Oh you should take more, oh you should take less, oh you should throw them out. Oh no, take them all at once.’ It’s very difficult, like it’s a mind game. It is very challenging I would say, but it’s not impossible.”
Holden urged seniors to take medicines only as prescribed, and if they have suffered drug abuse to “work a very strong program of recovery.”
Addiction isn’t the only risk with opioids. Sen. Susan Collins (R-Maine), chairwoman of the committee, said, “Older adults taking opioids are also four to five times more likely to fall than those taking nonsteroidal, anti-inflammatory drugs.”
That points to a vicious cycle. Taking opioids can lead to falls, falls can lead to pain, pain can lead to opioids and opioids can be abused. On top of that, doctors might not even realize the source of an elderly patient’s problem.
“Regrettably,” Collins added, “health-care providers sometimes miss substance abuse among older adults, as the symptoms can be similar to depression or dementia.”
Responding to myriad tales of abuses, like many other states, Missouri has reformed its asset forfeiture laws to require a criminal conviction before cash or property is seized and, in a bid to prevent “policing for profit,” to require that money seized by state law enforcement agencies goes solely to the state’s schools.
Under Missouri law, seized cash is supposed to go to the schools, but the cops have found an end-around. (Wikipedia)
Somebody needs to tell the cops. As Kansas City TV station KMBC reported, state and local law enforcement agencies seized more than $19 million in the past three years, but only some $340,000 has actually made it to the schools. That’s a measly 2% of the cash seized.That’s because police, with the help of the Trump Justice Department, are doing an end run around the state law. Under the Justice Department’s Equitable Sharing Program, which was suspended late in the Obama administration but reinstated last year by Attorney General Jeff Sessions, state and local law enforcement agencies can hand their cash-laden cases over to federal prosecutors instead of turning them in to local district attorneys. And when they do, the reporting agency gets to keep 80% of the seized cash, with the Justice Department getting the rest.
The scheme not only subverts state law by diverting much-needed funding for schools to police agencies, but also by allowing state and local cops to seize cash and goods under the federal law, which does not require a criminal conviction first. In this manner, Missouri’s cops are not only ripping off the schools, they are also giving a big middle finger to the state’s democratically elected representatives who passed the asset forfeiture reform law.
The cops like things just as they are.
“We can immediately put that back in our tool belt if you will,” said Major Derek McCollum, the head of the Kansas City Police Department’s Asset Forfeiture Squad. The money buys “computer type equipment, covert surveillance type equipment,” McCollum told KMBC, adding that he didn’t feel like law enforcement was taking money from the schools.
The Missouri School Board Association begs to differ.
“Absolutely, the constitution says it is,” said association attorney Susan Goldammer of the forfeiture money. “We still have school districts that don’t have air conditioning or have concerns about asbestos. We’ve got many, many school buildings in the state that are way more than 100 years old,” she added.
Instead of turning forfeitures over to the state’s school system, the state Highway Patrol spent $70,000 on new weapons. And in Phelps County, which sits astride the east-west throughway Interstate 44 and which profited the most from asset forfeiture, the sheriff spends the money on the department’s buildings — not school buildings.
State Rep. Shamed Dogan (R-St. Louis) is working on a partial fix. He has authored House Bill 1501, under which only cases involving more than $50,000 could be handed over to the feds. (He had originally pegged the figure at $100,000, but has now halved it after “pushback from law enforcement.”)
Dogan told KMBC that cases over $50,000 account for about 20% of asset forfeiture cases statewide and that he believes many smaller seizures are from innocent victims or involve rights violations.
“We can eliminate that incentive for them to just take money or take property,” Dogan said. “The government seizes their money and says, “we think you’re a suspected drug dealer. The government never produces any drugs, never charges you with a crime and then you have to spend more than they’ve actually seized trying to get your property back. That’s unfair.”
The $100,000 version of Dogan’s bill is currently stalled in the legislature. Facing law enforcement opposition, the House Crime Prevention and Public Safety Committee voted in February to postpone action on it, and the bill has no hearings scheduled and is not on the House calendar.
Perhaps he can get the $50,000 version moving. In the meantime, Missouri’s cops continue to perversely profit from prohibition, while the state’s schools are out of luck.
Small-town pharmacists dispense medication, of course. But they might also provide clinical services like immunizations and blood pressure screenings; consult on health issues; or even act as a de facto benefits or case manager for customers.
Pharmacies clearly are important to health care in rural communities. Yet nearly 500 rural communities in Washington lost their only retail pharmacy between 2003 and 2013.
Janessa M. Graves, an assistant professor at the Washington State University College of Nursing, is studying the issue.
“It’s a worrisome trend, and yet this is something that hasn’t been looked into very closely,” she said.
Graves’ research is specifically looking at retail pharmacies that serve people covered by Medicaid, the state-federal insurance program for low-income children and adults and people with disabilities. More children are covered by Medicaid in Washington’s “nonmetro” counties than by private insurance, and statewide, 91 percent of community pharmacies accept at least one Medicaid insurance plan.
Laura Forman, a WSU College of Nursing Honors student, assisted Graves on the first part of the research. They presented initial findings at a rural health conference in Spokane recently.
Graves
Graves said access to a community pharmacy is especially important in rural areas, which have trouble attracting health care providers.
“Where there’s a dearth of health care, a pharmacy can play an important role,” she said.
But some large counties have only a handful of retail pharmacies. Ferry County, for example, has a total area of more than 2,200 square miles, but has only a couple of retail pharmacies that accept Medicaid reimbursement. There are three in Lincoln County and two in Pend Oreille County. Spokane County has 93 such pharmacies, according to preliminary research by Graves and Forman.
Rural counties are sparsely populated, so the number of pharmacies per 10,000 residents is higher in Ferry and Lincoln counties than in Spokane County.
But those numbers don’t reflect challenges like driving long distances, over sometimes dangerous roads, to get to a pharmacy. And while mail-order pharmacies might be an answer for medications used to treat chronic conditions, they aren’t useful for filling prescriptions needed immediately, like an antibiotic.
The research is ongoing. Graves would like to know whether people in rural areas are driving long distances to fill prescriptions, and what the decline in rural pharmacies means about access to health care. She said the research could suggest potential solutions, like targeted policies to raise Medicaid reimbursement rates in rural areas, or other measures to encourage rural pharmacies to continue to accept Medicaid.
Graves was drawn to the subject because her research tends to focus on health systems and data. Plus, she grew up in a rural community and lives in one now and said, “I care a lot about rural communities.”
Retail pharmacists and specialty pharmacists working in the trenches may have heard whispers about something called “copay accumulator programs.” But with long lines at the register, phones ringing off the hook, 65 medication therapy management (MTM) consultations to do, 30 more flu shots to give and a jammed printer…I can understand why you haven’t had time to read up on them.
I’m a front-line pharmacist myself, and I understand your dilemma. Let me take a moment to explain this issue.
By way of introduction, let me express that this really is a big issue in my opinion. It was a major topic of discussion at the recent Asembia conference held in Las Vegas earlier this month.
Scott Dulitz of TrialCard, who attended the conference, posted on LinkedIn that “if this topic was hot last year, it was on fire by comparison at Asembia18.” Copay accumulator strategies by pharmacy benefit managers (PBMs) and health plans may be impacting some of your patients already.
At the heart of the copay accumulator program is the fact that pharma companies are actively involved, and have been for some time, in helping patients afford their medications when copays are beyond their financial reach. They do so through copay assistance programs and charitable foundations.
Thus, when a patient is confronted with an expensive copay, many pharmacies (in particular, specialty pharmacies), look for financial assistance for these patients.
This financial assistance covers the patient copay, often getting them through a high deductible or through the Medicare “donut hole,” to the point where the health plan now is responsible for the majority of the cost. And that is where the problem, from the health insurer perspective, begins.
A high deductible, copay or coverage gap period are, to put it bluntly, a mechanism to reduce utilization.
These large out-of-pocket oceans are simply too big for many patients to cross. But manufacturer assistance programs act like a lifeboat, safely helping patients cross the depths of these high-deductible seas.
The copay accumulator program, to continue the illustration, effectively shoots a hole in the bottom of the patient lifeboat.
These plans are designed to identify when patients receive financial assistance and not count such assistance toward their deductible, out-of-pocket limits or coverage gap. The result?
The benefit derived from these manufacturer programs, even if they amount to thousands of dollars, may be exhausted in several months and the patient is left facing the same high copay as before.
The whole issue of copay accumulator programs exposes the underlying tension going on in healthcare between pharma, and the insurer and PBM industry.
Payers point the finger at pharma for high drug prices. Pharmaceutical manufacturers point the finger at PBMs and high deductibles and copays which are not affordable without these coupon programs.
Neither side seems willing to admit that they are ultimately more concerned with their bottom line than with the patients they serve.
It’s pretty clear that while patients are not excited about the high cost of prescription drugs, they are equally unhappy with health plans stripping away their access through these copay accumulator plans.
A patient quoted in a recent Los Angeles Times article on the subject said, “It seems unfair. It shouldn’t matter to them who’s paying my deductible, as long as it’s being paid.”
As a pharmacist, I have to admit, I couldn’t agree more. While the ongoing battle over drug prices continue, I hate to see patients caught in the middle.
One cannot feel too sorry for either pharma or the PBMs, both of whom appear to be profiting pretty well in our healthcare system. But patients who work, pay premiums and now are stuck with unaffordable deductibles and copays are the ones who lose.
Personally, I’m not okay with that, and can only hope that employers will reject plans that offer such programs to them.
“We just want everyone on board to have the healthiest kids we can in our community,” one councilman said.
Author: Dennis Ting
Published: 6:31 PM EDT May 25, 2018
Updated: 6:38 PM EDT May 25, 2018
LOUISVILLE, Ky. (WHAS11) — Dining out with kids could be getting healthier. At least that’s what several Louisville metro council members hope after they passed an ordinance Thursday evening that will require Louisville restaurants to make sure children have healthy options in the menus.
“Nobody’s trying to play gotcha here,” Councilman Rick Blackwell, D.-District 12, said. “We just want everyone on board to have the healthiest kids we can in our community.”
The ordinance would require children’s meals at restaurants – defined as when several different items are bundled together – include either a whole grain product, a lean protein, a cup of fruits or vegetables.
If a drink is included in the meal, the default drink will now need to be listed on the menu as either water, milk (or a non-dairy alternative), fruit juice combined with water or a drink that has less than 25 calories per 8 ounces and no artificial sweeteners. Customers will still be able to request soda or another sugary drink.
“The hope is that an adult presented with that will more likely than not choose that option,” Blackwell said.
According to Blackwell, one of the co-sponsors of the bill, which passed with a 13-11 vote, the goal is to combat childhood obesity and the other health risks that come with it.
“We are looking for ways to make a dent in that,” he said. “So last night’s vote wasn’t a silver bullet. It wasn’t the one that’s going to make that all turn around, but it’s one thing that will make a difference, we believe.”
But not everyone believes the menu changes will lead to behavioral changes.
“I think that most people when they go into a restaurant have in mind what they’re going to get,” Kentucky Restaurant Association President and CEO Stacy Roof said. “As a parent, I think you know what you’re going to make available.”
Roof said she and other organizations and restaurant owners did talk with council members as they worked on the ordinance to give their opinions. She said while almost everyone can agree promoting childhood health is important, the ordinance could pose challenges for some restaurants.
“What is in print on restaurant websites, restaurant menus, the drive-thru boards that you see or the menu boards in the restaurant and quick-service operations, those will have to be changed,” she said.
Blackwell said the ordinance, if not vetoed by Mayor Fischer, will take effect in 120 days. Restaurants will then have one year after the ordinance begins to get everything in order before fines will be imposed.
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Next week, top executives from the nation’s largest distributors of prescription painkillers will testify before Congress about the role their companies played in the deadliest drug crisis in U.S. history.
Attorney General Jeff Sessions said that if he were still senator, he would have tough questions and choice words for the company executives.
“This has been a colossal detriment to America, and you have profited enormously by it,” Sessions said he would tell them. “And I’m not shedding any tears if you’re no longer making profits.”
In an interview with The Washington Post, Sessions said “I don’t have sympathy” for the distributors that are accused of flooding communities with powerful prescription painkillers. “They’ve made a bunch of money. Some of them have done it the right way, I know. But at some point, I think it’s fair to say that they were slow to recognize how much damage was being done.”
Sessions’s comments come as questions mount over how much responsibility opioid manufacturers, distributors and others within the supply pipeline bear for the epidemic that kills tens of thousands each year.
In recent months, Sessions has taken an aggressive approach, both with his rhetoric and a string of new initiatives. He said he was affected by the book “Dreamland: The True Tale of America’s Opiate Epidemic,” and the story of Purdue Pharma’s campaign to market OxyContin.
“Have you read ‘Dreamland’?” he asked. “For the first time, you get a glimpse of how it really developed.”
Sessions has proposed limiting the amount of opioids that companies can manufacture each year. He announced that the Drug Enforcement Administration also will share with 48 state attorneys general information from a database that monitors the flow of painkillers from manufacturers to distribution points, with hopes that it will aid their investigations.
The ARCOS database tracks controlled-substance transactions reported by manufacturers and distributors to the DEA. Much of the information is confidential, but Sessions said he would consider making more data available to the public.
He also created a task force to target drug manufacturers and distributors, raising the possibility of filing criminal charges against them if they break the law.
Purdue Pharma, which was fined $634 million for claiming its drug OxyContin was less addictive than other pain medications, declined to comment on Sessions’s remarks.
Cardinal Health said in a statement that it agrees with Sessions’s desire to reduce the number of opioid prescriptions and that the company “cares deeply about the devastation opioid abuse has caused American families and communities and we are at the table to help solve this complex national public health crisis.” Cardinal Health was fined $44 million in 2016 to resolve allegations that it failed to report suspicious orders of narcotics. In 2008, Cardinal paid a $34 million fine to settle similar allegations.
McKesson Corp. said that as a distributor it “does not drive demand or ‘dump pills’ — we fulfill orders placed by DEA-registered pharmacies, which correspond to prescriptions written by DEA-registered doctors.” McKesson agreed to pay $150 million in fines in January to resolve allegations that it failed to report suspicious orders of narcotics. In 2008, the company paid a $13 million fine for similar allegations.
John M. Gray, president and chief executive of the Healthcare Distribution Alliance, a trade group that represents distributors, said: “Distributors have no role in driving demand for pharmaceuticals, including opioids, and do not manufacture, prescribe or dispense medicines.”
A spokeswoman for the group that represents manufacturers said it supports a “wide array of proposals to prevent abuse and addiction.”
Opioid overdoses killed more than 42,000 people in 2016. A study released Tuesday by the National Institute on Drug Abuse said that 45.9 percent of these deaths involved fentanyl, a powerful synthetic painkiller, and that 40.4 percent involved prescription opioids.
The Justice Department filed a “statement of interest” in the lawsuits against drug companies brought by cities, counties and Native American tribes seeking reimbursement for the costs of the drug crisis. States and cities say their budgets are strained from the costs incurred as a result. Jails are over capacity. First-responder budgets are stretched. The number of children in foster care is at a record high.
The judge in the multi-jurisdictional case, Dan Aaron Polster, has said he wants to see a speedy settlement that will help end the opioid crisis. He has scheduled the first trials for March 2019.
The Justice Department argued in a court filing that the nation has deployed “extensive resources” to fight the opioid crisis, which has created a “substantial economic burden” on the federal government. Sessions said that the federal government also should be repaid for the costs it has borne.
“We believe that there have been improprieties in drug distribution,” Sessions told The Post. “We have an interest because the government has paid for a lot of this excess. A lot of this is paid for by Medicare, Medicaid, the [Department of Veterans Affairs]. And so we have an interest financially also.”
In Congress, a House Energy and Commerce Committee oversight panel is investigating whether drug distributors pumped millions of highly addictive pills into West Virginia, which has the nation’s highest rate of overdose deaths. Next Tuesday, current and former drug-company executives are scheduled to testify before the panel and expected to be grilled about why their companies flooded the state’s small communities with pills.
Sessions said that one of “the most significant” steps he has taken has been to create the Justice Department’s Opioid Fraud and Abuse Detection Unit, which focuses on investigating and prosecuting health-care fraud related to prescription opioids, including “pill mill” schemes and pharmacies that illegally divert or dispense prescription opioids.
“That has led to lots of investigations all over the country, and it’s pretty stunning, really,” Sessions said. “Sixteen doctors in [the] last takedown prescribed 20 million opioid pills. And one doctor we raided received $1 million in cash at his house. Lots of them have just made huge amounts of money.”
LAFAYETTE, Ind. (WLFI) – CVS and Walmart Pharmacies have stopped filling Lafayette Dr. Robert Bigler’s pain pill prescriptions. Patients are left wondering why.
For pharmacies no longer accepting Dr. Robert Bigler’s prescriptions, Brian McIntosh has a question.
“Should I make my next doctor’s appointment with you?” said McIntosh.
McIntosh has been seeing Dr. Bigler for about 14 years.
“I was diagnosed with Lupus. Lupus can cause different problems,” said McIntosh.
Problems requiring pain management and sometimes, opiates. However, McIntosh said Bigler doesn’t give them freely.
“There have been several times where I have requested a little higher dosage and he’s said no, we will work through this another way,” said McIntosh.
That’s why McIntosh was surprised CVS and Walmart decided to stop filling scripts written by Dr. Robert Bigler.
“Why they have picked him out is beyond me,” said McIntosh. “I know of no other doctors that are going through this.”
However, something similar happened to Pain Management Dr. Anthony Mimms in Indianapolis. He ended up suing CVS for defamation. He won a million dollars in trial court but the decision was overturned on May 9. Another trial has been requested.
“He follows the guidelines,” said Beth Carter.
Carter also goes to Dr. Bigler. She’s been denied at Walmart Pharmacy.
“And I asked them why and they said, ‘well we are not subject, we can’t tell you that,'” said Carter.
Telling patients why, could open pharmacies up to another defamation lawsuit. However, McIntosh thinks the public deserves transparency.
“There has to be a reason why they’re doing that so let us know at least what it is, pay me that courtesy,” said McIntosh.
Walmart refused to comment on the matter.
CVS said it has a program in place to identify prescribers who exhibit extreme patterns of prescribing high risk drugs such as pain medications. It said in some cases, following a thorough investigation, CVS may suspend the dispensing of controlled substances they write. However, they won’t confirm specific doctors and the results of those investigations.
McIntosh is currently going to Payless for his prescriptions, Carter is getting hers from Walgreens. However, what if more pharmacies follow suit? Will other local doctors be added to the list?
“I really hope not, that’s going to make a big mess,” said McIntosh.
If getting prescribed pain pills at the pharmacy gets more difficult, some fear patients will turn to the streets instead.
“It’s already happening as a result of what is going on,” said McIntosh. “They can buy it cheaper on the street, the drug is stronger, it’s more potent.”
“I’ve seen people do it and it’s scary. And I don’t want to lose no more friends to that,” said Carter.
Dr. Bigler’s office refused to comment on the matter. According to the Indiana Board of Pharmacy, there are no formal complaints against Dr. Robert Bigler. His license to prescribe is still active.
Krissy Houser is one of many chronic pain patients who are feeling besieged by new government and insurance company policies limiting prescription opioids.
The Bucks County woman was taking high doses of the highly addictive pain medications until her doctor got nervous in fall 2016. Federal officials were looking at his prescribing records, he told her, and she’d need to come down to the much lower dose — about a seventh of what she was taking — that was newly recommended as the ceiling for new pain patients by the U.S. Centers for Disease Control and Prevention.
Houser cried. She injured her back in a recreational vehicle accident in 2006, when she was in her late 20s. Two surgeries helped, but then she fell before the second surgery had healed. She had to leave her job at Merrill Lynch and go on disability. The opioids limited the pain enough for her to be able to help her mother, walk the dog, and see friends.
Since her doctor began slowly tapering her dose, she has suffered withdrawal symptoms and pain that is constant and intolerable, she said. Houser, who had weight-loss surgery before her accident, has gained 90 pounds since her pain treatment changed. She still has not quite met her doctor’s dosing goal. “I’ve lost friends. I’ve lost everything. I’m a shut-in,” she said.
Her mother now walks the dog. “That’s the hardest part,” she said. “She’s now taking care of me again.”
Houser sees herself as a collateral victim of the war on opioids. Experts say that most people with an opioid addiction today got started on prescription pain pills — either their own or someone else’s. New rules seek to contain the number of leftover pills available for diversion and reduce the number of pain patients who become dependent or suffer serious side effects. But longtime users with chronic pain contend that these rules are hurting law-abiding people. They and some doctors worry that the opioids pendulum, which initially swung too far toward prescribing the pills, has now swung too far toward taking them away.
Situations like Houser’s will likely become more common next January when Medicare starts enforcing its new rules on opioids, which will make it harder, though not impossible, for doctors to prescribe high doses. Medicare, which often leads on insurance coverage policy, is coming later to this issue. But, with its 58.5 million senior and disabled beneficiaries — Houser included — it wields huge influence.
In addition to rules from many private insurers and state governments that make it more of a hassle to prescribe high doses of opioids, doctors are also feeling pressured by law enforcement agencies, which monitor prescribing patterns, patients and their advocates said. Pain specialists say they’re seeing an influx of chronic pain patients who have been dumped by other doctors.
In part due to such restrictions, opioid prescribing has continued to decline from its peak in 2011. Yet U.S. doctors still prescribe more opioids per capita than doctors anywhere else in the world.
Should chronic pain patients be treated differently from people new to opioids?
Some chronic pain patients and experts argue that those who are accustomed to high doses and are doing well on them should be treated differently. Cutting their doses could lead to greater disability, depression, suicide and illicit drug use. Besides, they note, patients often don’t have access to pain specialists or the multimodal pain programs – employing not only medicine but also physical and emotional therapy — that research suggests is most effective.
Sharon Waldrop, vice president of the National Fibromyalgia and Chronic Pain Association, said most people on long-term, high-dose opioids failed every other option they tried first. The drugs improve their quality of life. “For a certain percentage of people,” she said, “it’s working.”
Courtesy of Kristen Ogden
Louis and Kristen Ogden live in Virginia. He takes high doses of opioids to treat his chronic pain. This photo was taken at her retirement ceremony in 2014.
Kristen Ogden, 65, lives in Virginia with her husband, Louis, 68, who has suffered terrible headaches and widespread pain since childhood. He is taking 28 times the opioids dose Medicare will soon use as a threshold for extra scrutiny. His body does not absorb medications normally, Ogden said. The drugs, she said, make it possible for the two of them to have a social life, and they improve his thinking ability. He says he never feels high. They were traveling to a pain doctor in California for treatment and paying $5,000 a month for the half of his dose that his insurer refused to cover. His doctor says he has faced pressure from the Drug Enforcement Administration, and is retiring.
Ogden worries that they will have “no quality of life” if Louis can’t get high doses of opioids. “I feel very frustrated because my husband has done very well,” she said.
Stefan Kertesz, an addiction expert and physician at the University of Alabama at Birmingham and the Birmingham VA Medical Center, started a petition against Medicare’s initial, and even stricter, opioids proposal. The adopted rules are less onerous, but still require a pharmacist to double-check with any doctor who prescribes more than 90 milligrams of morphine equivalent (MME) a day. (That’s the equivalent of 90 mg of hydrocodone, 60 mg of oxycodone or 20 mg of methadone. A calculator can be found here.) Hospice and cancer patients were excluded from the limits, flagged in 2016 by the CDC as a point above which the risk of dangerous complications and death rose.
But that recommendation was not meant, Kertesz and others said, as a goal for people already taking higher doses.
Kertesz said doctors know very little about what will happen when patients are forced to taper their doses. Many will have prolonged withdrawal symptoms, including depression. He worries they will turn to street drugs or even suicide. Many will need more mental-health support and monitoring.
“We are making large-scale, very aggressive policies in an arena where data is weak,” he said. “I don’t take it as a given that every person can be tapered.”
Curbing dangerous drugs
Supporters of restrictions say that opioids are dangerous, addictive drugs that, at higher doses, raise the risk for serious side effects and death. And, these experts say, there’s little evidence that high-dose opioids are any better than alternatives for chronic pain. The CDC found no studies of long-term use of opioids that compared them with other treatments.
Andrew Kolodny, a physician who is co-director of opioid policy research at Brandeis University, said that 90 MME is an “extremely high, dangerous dose.”
Courtesy of Andrew Kolodny
Andrew Kolodny is co-director of opioid policy research at Brandeis University and executive director of Physicians for Responsible Opioid Prescribing.
Many doctors – including area geriatricians – say Medicare’s actions will have more impact on its disabled patients than seniors, because older people usually are not on high doses of opioids, which are more dangerous for the elderly. The drugs make them more vulnerable to constipation, falls and mental fogginess, doctors said. At the same time, though, some older patients are also at risk from alternatives such as ibuprofen, which also can have significant side effects.
Kolodny suspects that fatal overdoses in seniors are underreported because their deaths are blamed on other medical conditions.
But he agrees with Kertesz that, during tapering, patients need extra care for both physical and emotional side effects. The drugs can paradoxically make patients feel more pain, plus pain is worsened during withdrawal. Anxiety and a sense of impending doom are also common during tapering. “These patients,” he said, “need a lot of support bringing their doses down.”
Kolodny said opioids should almost never be used for chronic low-back pain, fibromyalgia or chronic headache, but often have been. “What we’re really talking about are the victims of our era of aggressive prescribing,” he said.
In a recent study, Erin Krebs, a researcher at the Minneapolis VA Health Care System, compared two groups of patients with serious, chronic back, hip and knee pain. The group not on opioids tried an average of four pain medications, requiring careful trial and error under close medical supervision. Compared with the second group, who took opioids, those who had other therapies scored the same on measures of function, but reported less severe pain and many fewer side effects.
Krebs, though, signed Kertesz’s petition. “We need to make sure we’re doing this right and not creating a whole lot of new, unintended problems for people,” she said.
Courtesy of Rutgers New Jersey Medical School
Lewis Nelson is director of medical toxicology at Rutgers New Jersey Medical School
Lewis Nelson, a medical toxicologist who is chair of emergency medicine at Rutgers New Jersey Medical School, was on the panel that developed CDC guidelines. Chronic pain patients who have used opioids for years can overdose, he said, even when their dose stays steady. It can happen when another medication is added that interacts with the opioids. Sleep apnea can also be a factor. Or a patient can get a virus that affects the lungs, leading to dangerously low oxygen levels overnight – and death. “This is very, very common,” he said.
Except for metastatic cancer patients and people who are near death, Nelson takes a hard line. He says even after surgery or a substantial injury, few people need more than five days on opioids. “I don’t think anybody should be on them for chronic pain.”
Courtesy of Kristina Houser
Krissy Houser at Core Creek Park in Newtown, Pa.
Meanwhile, Houser is miserable with pain. She wishes she could afford medical marijuana. She thinks about suicide, but says her Christian faith keeps her from doing it. “There’s only so much a human being can take,” she said.
What insurers are doing
Locally, Independence Blue Cross now requires annual prior authorization for chronic pain patients on opioids, but doesn’t set a dose threshold.
Aetna, the region’s other dominant private insurer, requires prior authorization at 90 MME. It has new programs for patients who take long-term opioids with sedatives, which increase the odds of overdose, as well as for those on high doses or with a history of overdoses. It is urging subscribers to use alternative pain approaches, including acupuncture, physical therapy and chiropractic care.
From a numbers standpoint, the prescription restrictions seem to be working. Opioid prescriptions peaked in 2011 and doses also dropped in 2017, according to a recent report from IQVIA’s Institute for Human Data Science. Doses for 90 MME and up fell by 16 percent last year.
Drug overdoses, fueled largely by illicit opioids, have continued to rise.
