When Emma Stern’s private insurance changed two years ago, so did her pain management plan. The Oregon resident has insomnia and a painful chronic kidney condition that require careful medication. Stern’s new internist said the Drug Enforcement Agency (DEA) stripped her license for “overprescribing” opioids, so she could not provide Stern with necessary prescriptions. Instead, she referred Stern to a pain management clinic.
During a recent visit to her pain clinic, Stern’s pain management doctor informed her that her treatment plan was going to need to change again: Now, she would have to choose between taking Xanax and taking hydrocodone (also known as Vicodin). The doctor was not concerned that she was misusing her medications, but that law enforcement would come after him if “something happened to [her].” So, Stern had two options: medicate her pain, or get enough sleep. She chose the latter.
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While Stern’s story may seem extreme, her experience is representative of many chronic pain patients who have come up against various barriers that have been set by state governments, the medical field, and corporate pharmacies. According to recent CDC findings, 50 million Americans have chronic pain; although chronic pain affects people from all economic backgrounds, it tends to hit those in poverty the hardest. People in chronic pain tend to experience greater poverty, and struggle with the cost of medications and frequent pharmacy or doctor’s visits. The treatment of chronic pain also has major disparities when it comes to race, and black women in particular have suffered the consequences of those disparities.
Many of these access issues stem from a response to the opioid addiction and overdose crisis, declared a public health emergency by the Department of Health and Human Services in 2017. However, early response efforts have increased chronic pain and its consequences, leading to worse outcomes for chronic pain patients that should be addressed as a new public health crisis.
This crisis accelerated when the Centers for Disease Control (CDC) released their set of guidelines on opioid prescribing, intended for use by primary care providers, in 2016. The CDC has since clarified that the guidelines were recommendations, not strict policy, but the harm to many chronic pain patients like Stern has been done.
“The only treatment available [for my condition] at this point is treating the pain and the chief of urology at OHSU instructed my primary care doctor to allow me to have a monthly supply of opioid pain medication,” Stern said, but the results of opioid scaremongering have left her in agonizing pain instead. Part of the CDC’s 2016 guidelines, under the heading “Assessing Risk and Addressing Harms of Opioid Use,” stated that “[c]linicians should avoid prescribing opioid pain medication and benzodiazepines concurrently.” For someone with complex medical issues like Stern, this guideline is not useful.
Some government agencies are starting to recognize the consequences of cracking down on pain patients’ opioid prescriptions; the Food and Drug Administration (FDA) recently released a safety alert on the negative effects of sudden discontinuation or abrupt tapering of opioids, which can include “serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.” The authors of the 2016 CDC guidelines for opioid prescribing also recently clarified how its guidelines are meant to be used as a response to widespread misapplication of those guidelines.
The misconception that opioid prescriptions lead to opiate addiction has been widespread, and overarching state and federal measures to combat the opioid overdose crisis are reaching a fever pitch. There’s the Oregon Health Authority’s (OHA) now-tabled proposal to force-taper all Medicaid patients on opioids for certain chronic pain conditions; Senators Kirsten Gillibrand and Cory Gardner’s controversial proposal to limit all acute pain medication prescriptions to a seven day fill, which sparked massive pushback from the chronic pain and disability communities; and Ohio Senator Rob Portman, who favors a three-day fill limit. In contrast, the American Medical Association (AMA) has come out against arbitrary pill limits, as has a group called Health Professionals for Patients in Pain (HP3).
Very few opioid addictions begin with a patient who has a doctor’s prescription: Up to 80 percent of people with an opioid addiction illegally obtained pills from another source like a friend or relative first. While the opioid overdose epidemic from illegal heroin and fentanyl is a serious problem, federal and state actions to decrease the number of opioid prescriptions and/or pills in circulation overall will have — and are already having — a hugely negative impact on chronic pain patients who take opioid medications. While the number of pain prescriptions has declined since 2010, the number of deaths due to overdoses involving heroin and synthetic fentanyl has increased.
According to Thomas Kline, MD, a physician in North Carolina who maintains a list of chronic pain patients who committed suicide after being forced off of their medications, the anti-opioid hysteria that has taken root in the medical field and the federal government has resulted in “people [being] killed.”
Senators and state representatives are not medical doctors, and overarching government intervention of the kind that we are witnessing in private medical treatment can and does have consequences that are bad for chronic pain patients.
A one-size-fits-all policy, whether at the state or federal level, when it comes to chronic pain and opioids may have unintended consequences for chronic pain patients. Dr. Kline puts it more starkly: “Limiting the number of pills [that patients can get] is not going to work. All it’s going to do is screw people.”