The crackdown on opioids is having unintended consequences.
The push for fewer opioid prescriptions at lower doses and for shorter periods has increased suffering for some pain patients including those near the end of life. The emphasis on opioids has also overshadowed other forms of substance abuse that require attention.
With fatal overdoses soaring and millions addicted or dependent on powerful painkillers, there’s broad consensus that the number of opioids in circulation should be scaled back significantly. At the peak of prescribing in 2012, doctors wrote 282 million opioid prescriptions — enough for eight of every 10 Americans. And policymakers, who will hear testimony Tuesday from drug distributors about alleged “pill-dumping” in small towns in West Virginia, agree on the need to change prescription patterns to reduce the number of people starting opioids and to get people with inappropriate prescriptions off the drugs.
But sometimes solutions give rise to new problems, from hospital shortages of IV opioids to dying patients enduring avoidable pain. Here are some of the challenges state and federal lawmakers, physicians and patients, are beginning to confront.
Ready or not, we’re stopping your pain drugs
Doctors face intense pressure to decrease opioid prescribing and stop treating chronic pain patients with opioids long term. The government mental health agency doesn’t track the number of chronic pain patients like this, but some experts put the number as high as 10 million. Many doctors aren’t prepared (or, in some cases, willing) to gradually and appropriately transition them off their opioids, addiction experts say. Done badly, that tapering can push people toward street drugs like heroin – and there have been reports, too, of suicides of people left with uncontrolled pain.
“Some people will be tapered too quickly or in a way that is intolerable to them,” said Elinore McCance-Katz, the HHS assistant secretary for mental health and substance use.
“It’s not just people who are on chronic opioids that have difficulty tapering,” she added. Opioids create physical dependence very quickly, and even patients taking the drugs for only a few weeks may need to be gradually weaned to avoid withdrawal symptoms that can include muscle aches, vomiting and diarrhea, anxiety and insomnia.
Weaning patients off opioids should be a “cooperative process” between patient and physician — not an ultimatum or abandonment, said Sally Satel, a psychiatrist, Yale University School of Medicine lecturer and a resident scholar at the conservative American Enterprise Institute. “I’ve seen patients where doctors just say ‘That’s it, I’m done. I’m not going to lose my license over you and good luck,’ and that’s unconscionable,” she said.
Andrew Kolodny, the co-director of opioid policy research at Brandeis University Heller School for Social Policy and Management, said patients need a lot of support coming off opioids. “It’s not as easy as just telling a primary care doctor to lower the dose by X amount.” They may need social workers or psychologists to address anxiety, and they may need other ways of treating very real pain.
But Kolodny cautioned against the narrative that some patients should stay on their chronic opioids even if they are convinced they are doing just fine. “Opioids are lousy drugs for chronic pain and when you take chronic pain patients and get them off opioids their quality of life is improved. The tricky thing is, it’s very hard to get them off,” Kolodny said, calling for better wraparound support services for these patients.
Ignoring other addiction crises
Amid the intense focus on opioids, use of drugs like cocaine and crystal meth is exploding across the country, costing lives. “We treat drug epidemics like ‘whack a mole,’” said West Virginia Public Health Commissioner Rahul Gupta. “We get one under control, another pops up.”
Deaths involving cocaine increased 52.4 percent between 2015 and 2016, according to the CDC. Overdose deaths involving methamphetamine increased 30 percent between 2014 and 2015.
“We are seeing meth come back, we are seeing cocaine on the horizon,” said Jonathan Thompson, executive director of the National Sheriffs’ Association. “This is now a cyclical problem. So how do we prepare for it? Responding to opioids is different than responding to cocaine, which is different than responding to methamphetamine.”
Federal lawmakers in the last few years have focused funding specifically on opioid abuse, while leaving spending on other substance use disorders mostly flat. Trump in his 2019 budget proposal called for $13 billion to fight the opioid crisis, while proposing to cut other substance abuse treatment programs. Congress in 2016 authorized $1 billion in opioid funding over two years for states but some lawmakers — like Sen. Tammy Baldwin (D-Wis.), whose state has seen a spike in crystal meth deaths — want to give states more flexibility to spend that money. Illinois Democratic Rep. Jan Schakowsky at a recent Energy and Commerce meeting raised concerns about proposals to create opioid-specific treatment centers.
“I’m concerned about segmenting our health care system.” she said. “By doing this we ignore the fact that substance abuse disorders like alcohol, crack cocaine have ravaged communities for decades and we haven’t put forth the resource to address them. In fact in the past we called them junkies or criminals and continue to criminalize many addictions rather than treating that as substance abuse disorders.”
Taking away painkillers doesn’t take away the pain
Policymakers and insurers cracking down on access to prescription painkillers aren’t spending nearly the same effort increasing access to non-drug alternatives to opioids like physical therapy, massage or cognitive behavioral therapy.
“I’m seeing more changes to make it harder to gets opioids … than on how to help people who get in trouble with pain because they don’t have opioids,” said Cheryl Bartlett, the CEO of the Greater New Bedford Community Health Center, which treats patients regardless of insurance or income status.
Congress has “been big on promoting [nonopioid] alternatives” for the Defense Department and the VA. “Beyond that it’s pretty much just been lip service and it’s a little challenging how to craft legislation that affects what private payers are able to offer in this arena,” said Bob Twillman, executive director of the Academy of Integrative Pain Management, who’s membership includes a variety of health care practices from doctors to chiropractors and massage therapists.
One key barrier is that Medicare and Medicaid require a certain evidence threshold for alternative treatments before the government insurance programs can cover them.
“There actually is a fairly large body of evidence for many of these non-pharmacological treatments,” Twillman said. “The unfortunate thing is very little of it is randomized controlled trials and very little of it has long-term followup. The hang up is that it’s not the highest quality of evidence. But as I frequently point out to them they cover long-term opioid therapy and they don’t have any evidence for that either.”
Even when insurance does cover pain treatments that don’t involve opioids, the treatments tend to be more costly for patients. They also often require more time than popping a pill, a challenge for hourly workers who don’t have paid leave.
“It’s one thing for an insurer to cover [an opioid alternative], It’s another thing to cover it at a co-pay that the patient can afford. We need to stop making opioids the easy decision — in terms of writing prescriptions and patient access. Higher co-pays will stand in the way,” said Cindy Reilly, who recently left the Pew Charitable Trust, where she focused on issues around opioid use and access to effective pain management.
Care for the dying
There’s been a lot of research lately on what opioids don’t work for — but there’s no doubt that they can be essential for many patients nearing the end of life, or suffering metastatic cancer. CDC prescribing guidelines and state laws limiting prescriptions generally don’t restrict opioids for these patients — but hospice and palliative care physicians report that their patients are having a very difficult time getting the pain control they need.
“Almost every patient I have prescribed for recently has either a) run into pharmacies that no longer carry common opioids; b) cannot receive a full supply; and c) worst of all had their mail order pharmacy refuse to fill or have had arbitrary and non-science based dose or pill limits imposed,” said Sean Morrison, chairman of the geriatrics and palliative medicine department at the Icahn School of Medicine at Mount Sinai.
A combination of opioid shortages, prescribing limits and misunderstandings of policies combine to make it harder for hospice doctors to get their patients drugs like morphine.
“Even with exemptions for hospice care, prescription limits are still having an impact,” said Joe Rotella, the chief medical officer for the American Academy of Hospice and Palliative Medicine. “Patients have a tougher time getting these medications and it’s a lot more hassle for providers.”
Insurers who don’t fully understand the legislative limits may flag prescriptions. Pharmacies may question them after checking data banks on opioid use.
“I believe there has been an over-interpretation of dosing limits and threshold limits. CDC has always maintained that they meant for their guidelines to be just that, guidelines,” said Patrice Harris at the American Medical Association. “But unfortunately, payers and states are putting those hard dosage limits into statute and regulations.”
Hospital shortages of IV opioids
Hospitals in the U.S. are experiencing shortages of IV opioids for patients undergoing surgery, in intensive care units or being treated for cancer — all of which are appropriate uses for the powerful painkillers. The shortage of drugs like morphine and fentanyl began in mid-2017. The shortages weren’t directly caused by the focus on the opioid epidemic; it’s largely attributed to manufacturing delays impacting Pfizer. But ending those shortages has become more difficult because of measures put in place to address opioid overuse and diversion. And it‘s been serious enough that some hospitals have had to delay or cancel elective procedures, said Michael Ganio, directory of pharmacy practice and quality at the American Society of Health-System Pharmacists.
Normally when there’s a drug shortage, other manufactures try to boost production to meet the demand, but with controlled substances like opioids, they need special permission from the Drug Enforcement Agency, Ganio explained. Even getting permission to move raw materials for making opioids from one facility to another can be a challenge; a company with a problem at one manufacturing plant can’t simply ship the ingredients to another location and continue production.
“Our hospital pharmacists can’t be short of critical medications that are workhorse drugs that have been used for decades,” said Dan Kistner, senior vice president of pharmacy services at Vizient, the country’s largest hospital group purchasing organization. The DEA has taken steps to begin to ease the shortages. But Kistner said it’s been bad enough that pharmacists have had to spend hours and extra resources trying to acquire these opioids, instead of providing care to patients. And patients can have inadequate pain relief, or much more costly alternatives.