Part Two: Opioid Crisis – Unraveling the Myths
Efforts to solve the opioid crisis continue to focus on prescribing physicians. States have passed unnecessarily restrictive laws. Many doctors have cut off patients in desperate need. And raids by federal agents are forcing many more physicians to leave the field.
The Unintended Victims of the Opioid Crisis
(This is a continuation of a blog posted earlier in the month, read Part One here: Opioid Crisis – Unraveling the Myths)
After more than 18 years and 700,000 deaths, the U.S. has still not figured out how to stop the opioid crisis. In some cases, efforts meant to help have only made things worse. The Center for Disease Control’s prescribing guidelines are a tragic case in point.
As nationally recognized pain experts like Jennifer Schneider, MD, have said repeatedly, the CDC guidelines were themselves misguided and badly misinterpreted. An announcement by the FDA earlier this year suggested the extent of the damage. On April 9, the FDA reported that pain patients, denied the opioid treatment, were suffering “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.” Less than a week later, the CDC published a clarification in the New England Journal of Medicine. For many, the correction came too late. For many others, the harmful effects of the guidelines linger in laws and policies still on the books.
Pain patients are the most obvious victims.
When a patient called to say his pain regimen wasn’t holding him, his oncologist, Barbara McAneny, MD, increased his dosage from two to three pills a day. The patient’s primary care physician agreed to write the high-dose prescription. McAneny only learned later that the local pharmacist refused to fill it. The insurance company had denied the claim, he said. And according to the state’s prescription drug monitoring program, the patient had been given multiple high-dose prescriptions. The pharmacist suspected drug abuse.
“My patient, a very proud man, felt shamed and didn’t know what to do,” said McAneny. “So, he went home to be as tough as he felt he could be. That worked for about three days and then he tried to kill himself.”
McAneny, now the president of the American Medical Association, told this story to illustrate how the crackdown on opioids has harmed the approximately 18 million Americans who take opioids for chronic pain. Quantitative data is hard to come by, but the damage is clearly widespread. According to the New York Times, “more than 300 medical experts, including three former White House drug czars” signed a letter to the CDC in March contending that the guidelines were harming pain patients who had been “taking high doses of opioids for years without becoming addicted.”
It’s not the CDC guidelines per se that are hurting these patients. It’s the way insurance companies and states have translated them into rigid laws and policies. In response, many physicians have simply dropped pain patients or stopped prescribing opioids altogether. According to a study in the American Journal of Public Health, “In some cases, the change in policy was adopted literally overnight. Many patients seeking refills were simply told that they needed to stop taking opioids.”
That’s what happened to Jean Karchefsky, whose opioid prescription had been controlling severe pain from disk and bone degeneration for 14 years. After her doctor suddenly announced she could no longer treat the 63-year-old retired school bus driver, Karchefsky told the Cleveland Plain Dealer, she endured “an agonizing months-long ordeal that in the end left her to endure the ‘horrific’ nausea, anxiety, insomnia and diarrhea of cold turkey opioid withdrawal alone at home.”
New pain patients have suffered as well. A recent University of Michigan study found that 41% of 194 primary clinics surveyed refused to take new pain patients. And 33 states have enacted laws that deny patients recovering from surgery or an injury an opioid prescription that lasts more than seven days.
Patients in emotional pain are also being hurt
According to Schneider, some patients who start taking opioids for short-term physical pain, discover that their prescription also relieves long-standing emotional distress. “They may not even realize it,” said Schneider. “At first, they naturally assume they’re feeling better because they are in less pain. But then, when the injury heals and they stop taking the opioid, they start feeling bad.” Their requests to extend their prescriptions have nothing to do with addiction, she explained. “These patients, many of them young athletes, aren’t looking for a high. They just know that for the first time in a long time they feel normal, and they want to continue feeling normal.”
Researchers have not yet figured out exactly how opioids help relieve depression. But according to Anna Fels, a psychiatrist and faculty member at Weill Cornell Medical College, “research suggests that certain opioids may actually be useful in treating psychiatric diseases that have proved frustratingly unresponsive to current medications.” Irwin Lucki, Ph.D., who chairs the Department of Pharmacology at the Uniformed Services University of the Health Sciences, agrees. He recently posted an article titled, “Opioids, at Very Low Doses, May Provide a New Way to Treat Resistant Depression.”
Writing in the New York Times, Fels concluded, “It may seem counterintuitive and even dangerous to be considering the medicinal use of substances that are currently a scourge to our society. Yet opioids have a long history of being used to treat melancholia and other psychological disorders — right up until the 1950s, when the current group of antidepressants were discovered. Is it possible we’ve come full circle? We don’t know yet. But we owe it to our patients to find out.”
In the meantime, physicians intimidated by the current crackdown on opioid prescribing are more likely than ever to cut off patients who seek continued opioid treatment after their physical pain has ended. As with chronic pain patients, the result is more suffering, and potentially more illegal use of opioids as those in mental anguish seek relief wherever they can find it.
Physicians who treat pain patients are under attack.
In November 2017, agents of the U.S. Drug Enforcement Administration kicked in the front door of Dr. Forest Tennant’s home and clinic. They confiscated patient records, appointment books and financial documents. Their search warrant cited the many high-dose prescriptions Tennant had written as evidence of wrongdoing.
That same year, Tennant received a Lifetime Achievement Award for his half century of dedication to patients in intractable pain. He was never charged with a crime. But the DEA kept his case open and a year later, at the age of 77, he was forced to retire from practice. Many of the approximately 150 patients who depended on him said they felt desperate and devasted.
Tennant is not the only celebrated pain specialist who has been targeted. Past presidents of the American Academy of Pain Medicine, the American Society of Addiction Medicine, and the Tennessee Society of Addiction Medicine have all had their offices raided. None has ever been charged.
There are of course “bad docs” who should be prosecuted. And the Department of Justice, which includes the DEA, has achieved some positive results. In 2016, Dr. Hsiu-Ying “Lisa” Tseng, an osteopathic physician, was given 30 years to life for second-degree murder of three of her patients who overdosed.
But the continuing single-minded focus on opioid prescribing is outdated. As noted in Part I of this two-part series, prescriptions are no longer the cause of the opioid crisis. And targeting physicians who prescribe high doses of opioids is far more likely to snare responsible pain doctors like Tennant, who are willing and able to manage difficult cases, than criminals like Tseng.
And yet just last year, President Trump announced an initiative to, among other things, “cut nationwide opioid prescription fills by one-third within three years.” And law enforcement continues to use state prescription drug monitoring programs to identify physicians misusing opioids. “The government has this idea that if we can simply get everybody to quit prescribing opioids, we’re going to solve the whole opioid overdose death crisis,” said Schneider. “It’s nonsense.”
Raiding doctors’ offices without due diligence endangers patients and destroys careers. It also breeds fear among other responsible physicians. To take just one example, the North Carolina Medical Board recently found that 43% of those it surveyed, or 663 physicians, had stopped opioid prescribing altogether. The same thing is happening in other states as well, especially in those 33 states that have passed laws restricting prescriptions.The ones most impacted by these efforts are not the illegal drug suppliers. It’s the patients with intractable pain and undiagnosed mental health problems who are suffering, along with the dedicated professionals trying to care for them.