States Move to Control How Painkillers Are Prescribed

http://www.nytimes.com/2016/03/12/business/states-move-to-control-how-painkillers-are-prescribed.html?smtyp=cur

A growing number of states, alarmed by the rising death toll from prescription painkillers and frustrated by a lack of federal action, are moving to limit how these drugs are prescribed.
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On Thursday, Massachusetts lawmakers passed a bill expected to be signed next week that would sharply restrict the number of pain pills a doctor can prescribe after surgery or an injury to a seven-day supply. Officials in Vermont and Maine are considering similar actions, and governors across the country are set to meet this summer to develop a broad approach that could reduce the use of painkillers like OxyContin, Percocet and Vicodin.

The states’ push points to a looming change affecting how doctors use narcotic painkillers, or opioids, which are the most widely prescribed class of medications in the United States. The move comes against the backdrop of a public health crisis involving heroin-related overdoses.

The governor of Vermont, Peter Shumlin, said in an interview that states were taking action because drug industry lobbyists had the ability to block federal initiatives.

“The states are going to lead on this one because Big Pharma has too much power,” said Mr. Shumlin, a Democrat.

In recent years, some states have enacted tough new rules to reduce prescriptions for the drugs. But the pace of activity in states has grown so intense that experts are having difficulty keeping track. Currently, there are about 375 proposals in state legislatures that would regulate pain clinics and several aspects of prescribing painkillers, according to the American Academy of Pain Management, an organization for medical professionals that receives drug industry funding.

Even some physician groups that have long opposed legislative interference in how doctors practice have softened their stance. For example, the Massachusetts Medical Society, while opposing a proposal of a three-day limit on initial opioid prescriptions for acute pain, supported the seven-day cap adopted on Thursday by state lawmakers. Some doctors and dentists give patients as many as 60 or 90 painkillers containing narcotics such as oxycodone or hydrocodone, giving rise to potential misuse of the drugs or opening a door to addiction.

“Usually we are opposed to carving anything in stone that has to do with medical practice,” said Dr. Dennis Dimitri, president of the Massachusetts Medical Society. “But we are willing to go forward with this limitation because we recognize this is a unique public health crisis.”

In 2014, the death toll from overdoses involving prescription painkillers or heroin reached 28,647, a 14 percent increase from the previous year, according to federal data. Many recent heroin deaths involve the use of illicitly produced fentanyl, a prescription opioid often mixed with heroin.

It is unclear what effect the laws about prescription painkillers are having on death rates, which in some ways are the ultimate measure for any public policy aimed at reducing substance abuse. Some experts argue that measures to reduce prescribing painkillers may be having the unintended consequence of driving people to try heroin and other illicit drugs. Others dispute that, pointing out that the shift toward heroin use happened before the recent policy focus on opioids took hold.

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The use of opioids began to skyrocket in the 1990s in the face of claims by pharmaceutical companies and medical experts that opioids could be used to treat conditions like back pain and arthritis without fear of addicting patients. But as their misuse and abuse became rampant, public health officials, doctors, regulators and pain-treatment advocates remained deadlocked for years over how to address the public health crisis, arguing over whether tighter prescribing rules would penalize patients who needed the medications.

Some patient and medical groups maintain that little scientific data exists to warrant major new restrictions. But such arguments appear to be losing sway.

Along with the threat of addiction, there is also growing evidence that when given to patients in high doses, opioids pose a greater risk of overdoses as well as problems such as sleep apnea, sharply reduced hormone production and increased sensitivity to pain.

“We have a much better sense of the risks,” said Dr. Bruce Psaty, a researcher at the University of Washington in Seattle, who studies drug safety. “The culture has begun to change.”

Sales of opioids reached an estimated $1.98 billion in 2014, according to IMS Health, a research firm that collects prescribing data. There is little question that the drugs help tens of thousands of patients function better, including those suffering from chronic or long-lasting pain.

The moves now underway in Massachusetts and other states are not the first attempts to control how drugs are prescribed. Every state, with the exception of Missouri, now has a so-called prescription monitoring program to try to stop people from getting prescriptions from multiple doctors.

But while many of those programs have been voluntary, big impacts have occurred in places that require doctors to check the databases before writing a prescription.
These rules paint in such broad strokes that those with legitimate need who use opioid analgesic medications appropriately are lumped with…
These comments are from patients are compelling. I hope the NYT and lawmakers notice. However my hunch is that people who suffer or have…
Elizabeth Schaper 54 minutes ago

Having had 5 major spine surgeries during the past 11 years, at age 63 now, and about to undergo my 6th, I have been taking pain medication…

For example, after Kentucky passed a series of measures in 2012 including one requiring doctors to make such checks, opioid prescribing in the state fell 8.6 percent in one year, according to a 2015 report by researchers at the University of Kentucky in Lexington.

Some states have also started to look at a program used since 2012 by an insurer, Blue Cross and Blue Shield of Massachusetts, as a possible model.

Under the program, doctors cannot initially issue more than a 15-day supply of painkillers and doctors are restricted from prescribing more than 30 days’ worth of the drugs over a two-month period. In addition, they must seek prior approval from the insurer before prescribing long-acting narcotics such as OxyContin, except for cancer patients or those receiving palliative care.

Over the last three years, Blue Cross and Blue Shield of Massachusetts has found an 18 percent decline in the volume of opioid doses prescribed and a 50 percent drop in prescriptions for OxyContin and other long-acting opioids. Tony Dodek, an associate chief medical officer at the insurer, added that if it was developing the plan today, the insurer would most likely place a tighter limit on initial prescriptions.

Mr. Shumlin, the Vermont governor, said he expected that members of the National Governors Association would discuss opioid prescribing strategies when they meet in July.

“If we could adopt policies regionally or nationally, we could make some real progress,” he said.

As state initiatives gather momentum, there is even movement at the federal level.

The Centers for Disease Control and Prevention is expected to issue soon guidelines urging doctors to use opioids sparingly and treat pain first with nondrug approaches.

The effort has run into opposition. Some patient and doctors groups, including those funded by the drug industry, have charged that the guidelines were developed behind closed doors without their input and that they should not be published until more scientific evidence to justify them is developed.

In Washington, the Senate passed a bill on Thursday that would authorize funds for states to underwrite addiction treatment services and prescription monitoring databases, though it did not provide immediate money for the measures.

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