Second Opinion: Doc Says Blue Cross Opioid Policy Is Flawed

http://www.wbur.org/commonhealth/2014/04/10/second-opinion-doc-says-blue-cross-painkiller-policy-is-flawed

Amidst concerns over a massive national increase in the use and abuse of prescription painkillers, health insurer Blue Cross Blue Shield of Massachusetts instituted a new policy to reduce pain medication addiction and misuse.

This week The Boston Globe reports that as a result of the new policy, Blue Cross has cut prescriptions of narcotic painkillers by an estimated 6.6 million pills in 18 months.

But Daniel P. Alford, MD, an associate professor of Medicine and director of the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) Program at Boston University School of Medicine and Boston Medical Center, calls the policy “flawed and irresponsible.” Here’s Alford’s response:

By Dr. Daniel P. Alford
Guest Contributor

The Blue Cross Blue Shield of Massachusetts opioid management program was implemented to provide members with “appropriate pain care” and reduce the risk of opioid addiction and diversion.

In a recent Boston Globe report they claim “very significant success” with this program after 18 months because they have cut opioid prescriptions by 6.6 million pills.

Is this really a measure of success and if so, for whom? It likely saves Blue Cross money but has it successfully achieved their program’s stated goals? Does decreased opioid prescribing mean more appropriate pain care? Does decreased opioid prescribing reduce the risk of addiction or diversion, or does it decrease access to a specific pain medication (opioids) for treating legitimate chronic pain? Is the observed decrease in opioid prescribing evidence that opioids have been overprescribed, as Blue Cross claims, or is it proof that instituting a barrier to opioid prescribing (prior authorization) will decrease prescribing even for legitimate need? Are patients with chronic pain really benefiting from this program? I doubt it.

Adding yet more paperwork for physicians will not improve pain care, decrease addiction or the numbers of accidental overdoses from prescription opioids. Those physicians who are unwilling (or ambivalent) to prescribe opioids even when indicated will use the prior authorization requirement as an excuse to continue not prescribing. Those who are overly liberal in prescribing will figure out the most efficient way to satisfy the insurance requirements for approvals. Physicians who responsibly prescribe opioids – that is, prescribing them only when the benefits outweigh any risks — will be saddled with more administrative burdens to justify their well thought-out treatment decisions.

Some physicians may ultimately decide that prescribing opioids isn’t worth the trouble despite known benefits for some patients.

Some physicians may become overwhelmed and burned out with the large number of desperate patients seeking a doctor willing to consider prescribing opioids for chronic pain.

The Blue Cross program ignores an important principle highlighted in the 2011 Institute of Medicine’s blueprint for transforming pain care in the US — chronic pain is a chronic disease. As opposed to acute pain — that is, a symptom that resolves — chronic pain persists and often gets worse over time. By requiring prior approvals to prescribe any opioid for more than 30 days, Blue Cross is assuming that chronic pain will resolve by 30 days. This is a false assumption.

As a primary care physician who manages a large number of patients suffering from chronic disabling pain, I appreciate the complexities of balancing appropriate pain management with the safe use of opioids. I understand the clinical challenges of the subjective determination of whether a patient on opioids is benefiting (i.e., improved pain control and function) or being harmed (i.e., addiction). In addition I understand the difficulties of distinguishing the patient who is inappropriately “drug seeking” due to addiction, from the patient who is appropriately pain-relief seeking, as they both can present as equally desperate for help.,

However, if Blue Cross were serious about improving my ability to manage chronic pain safely, they would increase access to new, yet more expensive, abuse-deterrent opioids (e.g., reformulated OxyContin, Opana and Embeda) rather than continuing to prefer (Tier 1) easily altered and abused opioids such as methadone and morphine.

I worry about this flawed and irresponsible policy, and that while Blue Cross congratulates itself on a job well done — decreasing the number prescriptions of opioids — we are swinging the pendulum unnecessarily too far back to the days of under-treating chronic pain in a patient population that is too often stigmatized and lacks a unified voice.

Each year 16,000 to 18,000 pts die because they have acquired a “bug” that is resistant to all available antibiotics because antibiotics are – and have been – prescribed too often and inappropriately.  That is a similar number to the pts that they claim die of a prescription opiate overdose – and we don’t know how many actually obtained them legally… YET.. we don’t see any entity saying that we should be prescribing less antibiotics across the board.

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PROP Founder Calls for Forced Opioid Tapering

https://www.painnewsnetwork.org/stories/2017/7/20/prop-founder-calls-for-forced-opioid-tapering

“Outside of palliative care, dangerously high doses should be reduced even if patient refuses.  Where exactly is this done in a risky way?” wrote Andrew Kolodny, MD, Executive Director of Physicians for Responsible Opioid Prescribing (PROP). 

“I’m asking you to point to a specific clinic or health system that is forcing tapers in a risky fashion. Where is this happening?”

It’s not an idle question. About 10 million Americans take opioid medication daily for chronic pain, and many are being weaned or tapered to lower doses — some willingly, some not — because of fears that high doses can lead to addiction and overdose.

Kolodny’s Twitter posts were triggered by recent research published in the Annals of Internal Medicine that evaluated 67 studies on the safety and effectiveness of opioid tapering. Most of those studies were considered very poor quality.

“Although confidence is limited by the very low quality of evidence overall, findings from this systematic review suggest that pain, function, and quality of life may improve during and after opioid dose reduction,” wrote co-author Erin Krebs, MD, of the Minneapolis Veterans Affairs Health Care System. 

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How technology can help government fight the war on drugs

http://thehill.com/blogs/pundits-blog/crime/343106-how-technology-can-help-government-fight-the-war-on-drugs

Earlier this month, the Nashville District Attorney completely retired charges against a man named Christopher Miller who was arrested in May by the city’s police for attempting to sell the botanical substance called kratom.

The move brought renewed attention to this naturally occurring product that the Drug Enforcement Agency (DEA) last year proposed classifying as an illegal Schedule I substance — a plan which the DEA uncharacteristically withdrew, following a public comment period characterized by opposition from a wide range of constituents.

In a previous blog post about competing interests in the e-cigarette market, I described the so-called “Bootlegger and Baptist” theory of regulation, a realpolitik analysis of perhaps the single most effective type of issue-driven coalitions.

The theory’s title refers, of course, to the historical case of alcohol prohibition in America. At the time, those who favored criminalizing booze, beer and wine included mercenary figures who profited handsomely from a black market created by prohibition, along with teetotaling “do-gooders” concerned with saving souls.

The common purpose of these two disconnected groups with profoundly divergent motivations who nonetheless shared the same goal, led to the prohibition of alcohol in 1920.

It was arguably the government’s appetite for lost revenue from taxes on the sale of booze which eventually fueled a successful constitutional amendment in 1933, overturning what the Bootlegger-Baptist coalition had achieved thirteen years earlier.

With current annual opioid sales of around $11 billion in the U.S., projected to grow to $18 billion by 2021, an epidemic of addictions plagues nearly every demographic group in the country.

The fact that kratom helps many hooked individuals kick the dangerous habit, according to various experts and observers, means it has potentially significant economic impacts for pharmaceutical companies selling opioid painkillers.

Given the major addiction epidemic, clearly not all customers for the pharmaceutical companies’ products are consuming them for legitimate medical reasons.

On the issue of whether kratom should be criminalized, viewed one way opioid pharmaceutical makers approximate the Bootlegger part of the equation, without implying any nefarious intent or negligence.

Ostensibly, these companies would profit — or continue to profit, rather — from the DEA making kratom a Schedule I substance, since it purportedly functions as a “reverse gateway” drug, helping opioid addicts beat their habits.

During the public notice and comment process for the DEA’s plan to criminalize kratom, no vocal grassroots constituency emerged in support of the rule — no Baptist to match whatever economic interests (Bootleggers) may have favored the plan.

According to Regendus data, an analytics solution that applies Natural Language Processing to rapidly analyze sentiment contained in public comments, the vast majority of more than 24,000 submissions were strongly opposed to the DEA’s plan.

As a former federal prosecutor and criminal defense attorney, I was personally familiar with the DEA, whose policies and agents I regularly encountered on one side of a courtroom or the other.

On the defense side in particular, the courtroom is where the DEA normally faces opposition to its policies from certain elements of the public, i.e. the accused.

In the war on drugs, the agency’s rules have major, life-changing impacts on individuals, their families and communities.

Many observers of the DEA’s proposal to outlaw kratom and the agency’s eventual withdrawal in the face of strong public opposition on the issue have noted the rarity of the outcome.

In this case, the public leveraged its legal right to comment and influence a rule-making process, to stop a rule in its tracks before their government acted to make them defendants or criminals.

Instead of a loss in the courtroom, anti-kratom interests inside and outside the DEA lost their case in the rule-making process.

John W. Davis II is founder and CEO of N&C Inc., a provider of solutions such as Regendus that help advocates analyze complex content, discover insights, and better represent the interests of clients and stakeholders.

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Steve,

I just read your webpage concerning the interaction and legalities between pharmacists, physicians and patients.

Briefly, this is what happened to me. I’d like to know if I can file a civil lawsuit against this pharmacist.

For the last 6-years I have been on prescription pain medications. I’ve had 12 spine surgeries, and as such my entire lumbar spine is fused as is my entire cervical spine. Both are fused with “ladders and girders” with posterior and anterior entries. I’ve also had a lateral entry to fuse T12 to L5. Al the rest are fused, and I have chronic pain as a result. 

My Primary Care physician has monitored my surgeries, and has prescribed 120 mg of morphine and 120 mg of oxycodone to treat my pain. As such, my pain is a 0 or 1 throughout the day and night. Without it, my pain is easily a 4, and it can spike up to a 6-7 if I am active, or turn the wrong way with a fused spine.

I’ve used a Walgreens pharmacy for 5 of those 6 years. The Pharmacy Manager, “Dan,” has always monitored me closely, and has looked at me with a cocked eye. In short, he is routinely looking for some reason to deny me those medications. I am a Ph.D. Medical researcher. I travel frequently. As such, I sometimes need to fill the script early. Other times I am late in picking up my meds. Whether I am early or late, Dan is always grilling me with pill count questions, as well as questioning my reasons for being early. When I travel, I often have to refill a few days early. Sometimes, I’m late getting back from out of state, and I don’t pick up the medications until I’m obviously back in town. How I manage that medication (early or late) is between myself and my physician. I see him in office every time these meds are refilled. He asks me to provide proof of a flights or reasons for having to refill early. He is my physician, and he monitors my refill schedule and the reason for that early or late refill requirement.

I provide “Dan” photo copies of my plane tickets when I refill early. And my last refill was 06 June 2017. When that refill occurred, the pharmacist who refilled it, had a conversation with my physician. The physician was angry, accused the pharmacist of playing doctor, and produced other extenuating and mitigating issues—bottom line, he made it clear that he would not tolerate a pharmacist playing doctor and directing me to withdrawal. The pharmacist agreed to refill the meds on the phone. However, when I walked up to the pharmacy counter, the pharmacist present, said she would refill the morphine, and oxycodone this time, that she would refill the morphine on 6 JUL, but stated, she would not refill the oxycodone until 13 JUL 2017. This meant I would not have full medications on the 06 JUL refill date, instead, I would be forced to wait until 13 JUL to refill my oxycodone.

As such I was forced to managed my medications with what I had available. Since the female pharmacist told me she would not refill my oxycodone until 13 JUL; this meant I could not take the medication as prescribed. In other words, she and Dan did not care about the 06 JUL date—they were going mandate that I not refill until 13 JUL.

I understood I would have to miss doses and stretch the medications out until after 13 JUL for refill. This is why I did not visit my physician until the 19th of JUL, and then try to have the pharmacy refill on the 20th.

On 20n JUL, “Dan” refused to refill the medications. Further, he grilled me on pill counts, asked horribly personal questions and made absolutely inappropriate allegations that I had been deceptive with him, that I had lied to him, and more. He wanted to know if I’d gone into withdrawals. He wanted to know if my physician knew I was in withdrawal. He then started telling me (with the entire staff listening) that I lied about plane flights, and that I did not take my medications as prescribed. My efforts to tell him that it was his staff who pushed my refill date out of range for me. I also asked him if he was calling the airlines to see if I canceled my flights or not. He admitted he had done this. I told him he had greatly exceeded his scope of practice; that he was not a private investigator, and I doubted Walgreens would stand behind him on that kind of conduct. He continued speaking disrespectfully of me, and of my doctor, and said, “you are not answering my questions to my satisfaction, perhaps that “hot shot doctor” you have can do it, but I’ve been on hold with his office for 20 minutes.…etc., etc..

Angry, I snatched my scripts back and walked out.

I want to sue him civilly, for his calling the airlines to check on my flights, for calling me a liar, for telling me in front of everyone that I was deceptive. I want to wipe that smart ass smirk off his face. My physician, is going to call him and let him have a piece of his mind as well, but I want to take it further. I feel he violated my civil rights, among other things. To be clear, I did cancel my flight one time—why? Because I thought I was having a heart attack. The flight attendant called paramedics and I was escorted off the plane and taken to the closest emergency room. I was admitted into the hospital where I stayed for the next five days undergoing cardiac work ups.

What do you think? What can I do to remedy this?

I have migrated my entire prescription file (15 scripts + 2-pain meds) to another pharmacy that was ecstatic. The other 15 meds are cardiac and hormonal meds.

I would appreciate any feedback you might provide.

Thank you.

Filed under: General Problems | 5 Comments »

DEA clarifies guidance on forwarding unfilled e-prescribed controlled substances

http://www.drugstorenews.com/article/dea-clarifies-guidance-forwarding-unfilled-e-prescribed-controlled-substances

Filed under: General Problems | 4 Comments »

The WAR on Pain Patients Continues ! Politicians Don’t Care People Are Living in PAIN !

https://www.dailykos.com/stories/2017/7/8/1678907/-The-WAR-on-Pain-Patients-Continues-Politicians-Don-t-Care-People-Are-Living-in-PAIN

  I have not written a Pain diary in a little while. I have been kind of busy dealing with my own medical issues including continued pain and cancer. However I have been keeping up on what is going on around the country in regards to Pain Patients. I have to say I am so saddened by the current atmosphere of negativity towards Pain Patients as well as the demonization of opioids by those in government like the CDC, the DEA and even idiot politicians who are reacting to the so called opioid epidemic as they react to most things, by doing the worst possible things that won’t fix the situation. So many states are passing Opioid prescription laws based off of the supposedly “Voluntary” CDC guidelines it is ridiculous. Many are including exceptions for chronic pain patients but many are not. Meanwhile we have doctors dumping patients as they run in fear of the DEA investigating them. The overall result is many chronic pain sufferers are feelling like the Government has declared war on THEM specifically and individually ! 

Can you imagine what it is like to feel your government has declared war on you ? It sure as hell is not fun ! Study after study have shown that chronic pain patients are the least likeliest to become addicts with rates of addiction in the studies from 1% to about 5%. The CDC’s own information is showing that illegal Fentanyl has replaced prescription opioids as the leading cause of opioid deaths yet the persecution continues for chronic pain patients while doing exactly ZERO to help with the addiction issues facing America. Politicians at both the State and Federal level are cutting funds to addiction counseling and treatment at a time when addictions are rising. Politicians on all levels are

scrambling to be seen as doing something to combat the addiction menace yet they don’t want to spend money to do that ! The result is chronic pain patients are being made the scapegoats and that is resulting in a rise of pain patients receiving less treatment or even no treatment to combat their daily pain. Can anyone guess what that will lead to and has been leading to ? Yep ! A rise in chronic pain patients taking their own lives. This is adding to the statistics because the idiots at the CDC are including them into the opioid death stats. 

     The CDC guidelines rolled out last year are a nightmare for chronic pain patients. As I stated above these are supposed to be Voluntary yet we have politicians pushing the 90 MED dosing limits as law plus Insurance companies are getting into the act as well. What is worse is that those very guidelines were developed not with input from those directly involved in the care of chronic pain but rather almost exclusively by a group called PROP. This group runs a bunch of addiction treatment centers and has a very vested interest in getting everyone off of opioids as it will greatly increase their business ! Every single chronic pain patient who has been on opioids for any length of time will be dependent upon the

drugs. This is not to say that they are addicted as Andrew Kolodny insists in every possible forum he can, but rather it means that when the drugs are withdrawn the patient will fall into withdrawal. To Kolodny this means one thing ! ADDICTION ! To the rest of the thinking medical profession it means that the person has basically gotten used to having the drugs and care needs to be used when lowering the dose or cutting it off all together. Some prescribers advocates not for titration down but rather cold turkey yanking of all opioids. ( Titration is the stepping down or up of a dose of medicine to find the best result for the patient or in the case of down to counter the withdrawal symptoms so they are not life threatening. ) Yes going cold turkey from a high dose of opioids can be life threatening fro the withdrawal symptoms. This does not even cover the fact that the patient will have a return to high levels of pain. Pain that they had thought and HOPED was behind them. It also means a loss of quality of life. It means no longer working or in some cases even getting out of bed. To many chronic pain patients this is a DEATH SENTENCE and all because a group of greedy doctors decided to increase their business by proclaiming opioids BAD !  

    Let’s take a look at what chronic pain feels like ! Most people are lucky enough to have had no real experience with pain. Some may have experience with acute pain. This is short lived pain such as breaking an arm or other bone. Unfortunately sometimes acute pain turns into chronic pain and other times there is no real start to the pain. No one things that can be pointed at to say There is the cause” ! This is more likely in the case of back injuries where the damage is not done in one big event but rather by misuse or abuse over time, lifting wrong, doing more than you should and so on. The spine becomes more and more damaged over time leading to more and more pain. This is a lot of my chronic pain. I was a dumbass when I was younger and figured I could do anything. Yeah where is my time machine so I can go back and kick myself in the ass ? Because of that stupidity I have endured multiple operations on my back as well as multiple procedures such as epidurals and RF Ablations and other shots to try and block the pain. I have also endured living with a pain level of 8 for years. Most people would have headed for the ER when it got above 6 or 7 but chronic pain patients have learned how to function at that level of pain. To us it seems NORMAL ! Think about that for a minute. Such intense pain that you should go to the ER is your normal state. What you wake up in the morning to ( If you were able to sleep at all. I was lucky if I got 4 hours a night) and what you go to bed at night with. It NEVER goes away ! It NEVER Stops ! It changes your thinking. You become depressed. Your life gets smaller. You stop going out with friends or family. You may miss work a lot ! This causes you to become more depressed. You do what you have to get through each day and then do it again the next day. That kind of life SUCKS ! You jump at every chance to get the pain down. Trying new therapies until you have tried them all. Then you find a doctor who will prescribe an opioid to you and the pain drops. You work with the doctor and increase your dosage and now the pain is manageable, it is down to a 4 or less if you are lucky. You have your life back. Now you have someone who wants to end all of that and you can do nothing to stop them. It’s not because you are bad or did anything wrong other than to use opioids to get a handle on your pain. You have become almost a criminal in the eyes of society. Doctors and others in the medical profession suddenly are looking at you like you are a drug addict. You have to go to multiple pharmacies just to get your script filled while dealing with the looks and accusations both silent and aloud of the pharmacy staff. Your life still SUCKS but at least the pain is down. That is what chronic pain looks like and feels like. Before you condemn someone for using opioids as they have been prescribed by a doctor, you might want to think for a moment.Think if you want to be stigmatized for trying to get out of pain. 

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US DEA Says They Shut Down “Dark Net” Market for Heroin, Fentanyl

www.nwigazette.com/2017/07/20/us-dea-says-they-shut-down-dark-net-market-for-heroin-fentanyl/

“This is likely one of the most important criminal investigations of the year taking down the largest dark net marketplace in history”, said Attorney General Jeff Sessions. Guns, drugs and illegal documents allegedly traded on “dark net” site Alphabay

July 20, 2017-The United States Drug Enforcement Administration announced today that they shut down a “dark net site” which they allege was linked to the illegal sale of heroin and fentanyl. “The Justice Department today announced the seizure of the largest criminal marketplace on the Internet, AlphaBay, which operated for over two years on the dark web and was used to sell deadly illegal drugs, stolen and fraudulent identification documents and access devices, counterfeit goods, malware and other computer hacking tools, firearms, and toxic chemicals throughout the world” the agency announced.

The massive international criminal investigation was led by law enforcement officials from the United States and included authorities in Thailand, the Netherlands, Lithuania, Canada, the United Kingdom, and France, as
well as the European law enforcement agency Europol. “On July 5, Alexandre Cazes aka Alpha02 and Admin, 25, a Canadian citizen residing in Thailand, was arrested by Thai authorities on behalf of the United States for his role as the creator and administrator of AlphaBay. On July 12, Cazes apparently took his own life while in custody in Thailand. Cazes was charged in an indictment (1:17-CR-00144-LJO), filed in the Eastern District of California on June 1, with one count of conspiracy to engage in racketeering, one count of conspiracy to distribute narcotics, six counts of distribution of narcotics, one count of conspiracy to commit identity theft, four counts of unlawful transfer of false identification documents, one count of conspiracy to commit access device fraud, one count of trafficking in device making equipment, and one count of money laundering conspiracy. Law enforcement authorities in the United States worked with numerous foreign partners to freeze and preserve millions of dollars worth of cryptocurrencies that were the subject of forfeiture counts in the indictment, and that represent the proceeds of the AlphaBay organizations illegal activities” officials stated.

“On July 19, the U.S. Attorneys Office for the Eastern District of California filed a civil forfeiture complaint against Alexandre Cazes and his wife’s assets located throughout the world, including in Thailand, Cyprus, Lichtenstein, and Antigua & Barbuda. Cazes and his wife amassed numerous high value assets, including luxury
vehicles, residences and a hotel in Thailand. Cazes also possessed millions of dollars in cryptocurrency, which has been seized by the FBI and the Drug Enforcement Administration (DEA)” the statement continues. Legitimate cryptocurrency trading can be done with the help of brokers such as IronFX, and  IronFX complaints section gives an idea of its functions.

This is likely one of the most important criminal investigations of the year taking down the largest dark net marketplace in history, said Attorney General Jeff Sessions. DEA alleges that Alphabay boasted over 40,000 active sellers and 200,000 users. “Around the time of takedown, there were over 250,000 listings for illegal drugs and toxic chemicals on AlphaBay, and over 100,000 listings for stolen and fraudulent identification documents and access devices, counterfeit goods, malware and other computer hacking tools, firearms and fraudulent services.”

Officials say the investigation is related to numerous pending prosecutions in the United States and investigation is ongoing. Charges contained in an indictment or complaint are merely allegations, and the defendant is presumed innocent unless and until proven guilty beyond a reasonable doubt in a court of law.

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Trump administration wants to rollback controversial civil forfeiture limits

http://www.wtsp.com/news/politics/trump-administration-wants-to-rollback-controversial-civil-forfeiture-laws/457901213

U.S. Attorney General Jeff Sessions said this week that the new administration plans on increasing the use of civil asset forfeiture, a controversial technique that allows police to seize cars, cash, and other property from individuals, even if they weren’t charged with a crime.

10Investigates was one of many news outlets to expose civil forfeiture abuses in recent years, and in 2015, the Obama administration drew praise from many Democrats and Republicans after it tightened some of the federal rules on seizures, aiming to limit abuses.

In the last decade alone, the Drug Enforcement Administration (DEA) reports seizing more than $3 billion from individuals who were not charged with crimes.

But Sessions said by increasing the amount of property seized, the government could better-target drug traffickers.

That drew sharp criticisms from the Institute for Justice Director, whose senior attorney, Darpana Sheth, said in a statement, “Civil forfeiture is inherently abusive. No one should lose his or her property without being first convicted of a crime, let alone charged with one. The only safeguard to protect Americans from civil forfeiture is to eliminate its use altogether. The Department of Justice’s supposed safeguards amount to little more than window dressing of an otherwise outrageous abuse of power.

“We have consistently warned that the modest reforms put in place in 2015 could be rolled back with the stroke of a pen—and that is precisely what Attorney General Sessions has done today. The DOJ’s directive, announced to a room full of law enforcement officials who stand to reap the profits of this new policy, shows the fundamental absurdity of a system of justice which prioritizes funding law enforcement over protecting constitutional rights or fighting crime.”

Following 10Investigates’ civil forfeiture stories in 2015, Florida joined 23 other states in passing recent reforms on the issue.  Florida law now requires a conviction for law enforcement agencies to permanently keep your property, but loosening the federal restrictions could open a new window for Florida law enforcement agencies to seize assets under federal law.

Find 10Investigates’ Noah Pransky on Facebook or follow his updates on Twitter. Send your story tips confidentially to npransky@wtsp.com.

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New Opioid Guidelines Redefining ‘Compassion’ For Montana Doctors

http://mtpr.org/post/new-opioid-guidelines-redefining-compassion-montana-doctors

As the nation faces an epidemic of opioid drug abuse after a decade of aggressively prescribing narcotics , Montana doctors are becoming more cautious about giving painkillers to chronic pain patients.

It’s changing some patients ability to get treatment and what is considered compassionate care for chronic pain.

Last spring, the federal Centers for Disease Control and Prevention issued new opioid prescribing guidelines for doctors, designed to address the national epidemic.

In response, Butte Doctor Shawna Yates, the Medical Director of Southwest Montana Community Health Center, sent a letter to pain patients saying the clinic would no longer prescribe high doses of opioid painkillers.

“For me, personally, I really do try to stress that I believe in their pain,” Yates says, “that I understand where the concern that they’re having is coming from.”

But Yates says, her clinic’s new policies for the highly addictive drugs have caused a lot of patients to seek care elsewhere.

“I’ve said it more often in the last six months than ever before. I’m not leaving them. If they decide to leave, they’re leaving me.”

The CDC guidelines encourage primary care doctors to become less dependent on opioid medications for treating chronic pain because of the drugs’ serious side effects, including addiction.

The Butte clinic started tightening its prescribing policies back when it had about 700 pain patients coming in for treatment, years before the CDC released its guidelines.

It did things the CDC guidelines would eventually call for, like random drug tests, to make sure patients weren’t abusing their medication, or taking additional drugs. The clinic also required patients to only fill their prescriptions at one pharmacy.

“And many of those patients left” Yates’ clinic, she says. “There are many patients that aren’t willing to follow those recommendations.”

After the clinic put in the additional rules for pain treatment, and sent out a letter telling patients the clinic was adopting the federal guidelines, implementing a cap on how many pills it prescribed, about 400 patients left the clinic.

Doctor Andrew Kolodny, with the national advocacy group Physicians for Responsible Opioid Prescribing, says lowering the limit on prescription painkillers is a good policy and it’ll help patients who are harmed by high doses.

“For patients who are being required to taper down who are on high doses, that’s appropriate,” Kolodny says.

Kolodny is also the co-director of the opioids policy research collaborative at Brandeis University in Boston.

“As Doctors start to figure out that we shouldn’t have been prescribing in this way, these patients are at risk of being cut off from a legal supply of opioids,” Kolodny says. “And that’s why we really do need a compassionate response for that population.”

Kolodny says the problem isn’t people using opioids because it makes them feel good, snagging a few pills to get a quick high. The issue, he says, is the millions of Americans who were legally supplied, and hooked, on these drugs during an era of medicine where opioids were believed to be a good option to treat pain.

Now, Kolodny says the most compassionate thing doctors can do is slowly, and safely, begin to take away the painkillers and start treating these patients for narcotic addiction. Because he, and some doctors around Montana, say regular use of opioids can actually make pain worse.

But pain patients like Dalaine Propp don’t like being told they drug abusers.

“We either do what they say we do or we get kicked to the curb,” Propp says.

Propp is a member a pain patient support group in Great Falls. They got together because they feel they’re being treated unfairly. There’s about 100 members in the group’s Facebook page, and this spring, a couple dozen people showed up to the group’s first meeting.

Propp says she’s tried alternatives to opioids.

“I did the physical therapy, we looked at the surgery option, we’ve done injections, and unfortunately the only thing that has kept me working and kept me going was the opiate medication,” she says. “I think this whole thing with the CDC has scared even regular practitioners to even start people on any kind of pain regime.”

“I have no doubt that there are patients who are telling you that they feel agonizing pain,” Kolodny says,”and then they take their opioid and they’re able to get out of bed and function and brush their teeth and have some type of life, and that without the opioid they wouldn’t be able to get out of bed and they’d feel like they want to commit suicide.

“I can tell you that’s exactly how people who are heroin users who are opiate addicted feel until you use your first dose of heroin in the morning you’re feeling agonizing pain and discomfort,” he says.

Kolodny says too few doctors who prescribe opioids also prescribe drugs that can help patients wean off the painkillers. If doctors want to help chronic pain patients move past opioids, he says, more doctors need that addiction medication training.

There are patients who say that once they got off opioids, it became easier to deal with their underlying pain issue, some describe it like a fog being cleared.

At the clinic where Doctor Shawna Yates works, in Butte, patients are required to go to mental health specialists and encouraged to keep up a good diet and get enough sleep.

“I think the biggest thing we need to do moving forward as a culture is find better ways to treat pain,” Yates says.

“The hardest part is to know that there are people out there that are not getting good pain relief, and with a culture that is getting older and that are suffering, that’s the part that bothers me,” she says. “We can take stuff away, and we can know that there is harm related to this. I don’t think the biggest challenge is taking these away. I think the biggest challenge is finding out what we are going to do in place of it.”

Yates says as she, and other doctors learn more about how to treat pain, she wants patients to know she’s not abandoning their care, even if that’s exactly how some patients see it.

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Dr. Andrew Kolodny has issued an epic challenge to the pain patient community. He wants to know — “Outside of palliative care, dangerously high doses should be reduced even if patient refuses. Where exactly is this done in a risky way?” and, “I’m asking you to point to a specific clinic or health system that is forcing tapers in a risky fashion.” Of course, pain patients must respond. If you have been forced to taper and you have been harmed by a specific doctor or clinic, please issue a tweet in reply to Dr. Kolodny @andrewkolodny. If you don’t have a twitter account, now is a good time to get one. Don’t be shy. Don’t hold back. Tell it like you have experienced it in 140 characters. COPY, PASTE, SHARE.

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