Laws are going into effect soon that will cap the amount of opioid drugs a patient can receive. Medical use does lead to a lot of addiction and overdose, so I think this might be a good idea. It will also reduce the issue of drug diversion. Of course, we need serious reform in how we treat addicts, but overusing dangerous drugs is not a good healthcare policy. Opiate addiction is a huge problem in Maine, and it is good to see the legislature do something, but is this the right way to fight it?
Good motives, fair science backing the laws, but it’s always dangerous trying to pass laws on how to practice medicine.
I agree that limits on how much opioid meds should be prescribed for chronic, non-malignant pain are good ideas. Best data shows that above a certain dose, pain is relieved no better but there are more dire consequences like unexpected death. So we need good guidelines on that. But laws? Well, that’s a sticky issue.
I just hope these constraints are not applied to malignant pain, such as from cancer and other painful life-ending disease processes. There, the patient may require extremely high doses to keep comfortable up to the end. Sadly I didn’t see mention of an exception for such cases in the link provided.
So color me wary. And I am an opioid prescriber. One who very infrequently treats chronic pain with long-term opioids.
I’d rather see legislation requiring (and funding) additional medical evaluation. I’ve known people in severe pain that was mitigated with opioids and who were cut off due to new standards. One committed suicide because there was no relief for his intractable pain. That’s not right.
I’ll second that I think it’s generally a mistake to make laws about how medicine should be practiced-- exceptions for things like laws that prevent insurance companies from doing essentially the same thing (in other words, I’m in favor of laws that say insurance companies can’t dictate how long a hospital stay after a particular procedure should be, or that something must be done outpatient).
Isn’t there some way to track where prescriptions drugs that get into the black market come from, and also track people who apply for any kind of public assistance for rehab or disability as an addict, or have insurance companies report then by a number (that is, anonymously), and track them back to doctors, to try and figure out if certain doctors are either creating disproportionate numbers of addicts, or writing prescriptions that are not being used by the patient, but resold? If you could target problem doctors for suspension of opioid-writing privileges-- or maybe fine them the first time, and report them to their insurers, and save suspension for doctors who continue to be a problem.
I realize that is very complicated, but not every doctor is a problem, and the “one guy craps his pants; everyone wears a diaper” solution is not good.
For example, a lot of acute care clinics around here will not prescribe opioids at all, and some will not prescribe them after 5pm. This means that only people who either have a private doctor, or the job flexibility to go to the clinic outside normal working hours can get a prescription for opioids.
Just to illustrate where this kind of policy can take you, people on SSRIs, a very common category of antidepressant that includes Prozac, cannot take OTC cough medicine, because it can cause a serotonin storm when mixed with an SSRI. That leave two prescription choices for cough medicines: codeine and tessalon. They are both very effective. Codeine has been around forever, and is really cheap, even for people without insurance. It’s also an opioid. Tessalon is new and expensive, and not always covered by insurance (because codeine is an alternative). Someone who needs a limited prescription of codeine as a cough medicine is unlikely to become an addict, because the prescription is likely to be for 10 days with no refills. Now, it could end up on the street, I suppose, but it’s going to be a drop in the bucket, and most people are going to take at least part of the prescription. If people are going to “abuse” it, it’s more likely to be in the form of keeping the unused portion until someone else in the household gets a cough.
Because this ends up effecting policies of clinics and ERs more than private doctors, it ends up disproportionately effecting poor people. Now, people on SSRI are likely to either have work insurance, or be on disability and have a doctor, but they get sick on the weekends, and then there are lots of poor people who twist ankles, break fingers, and get injuries that are pretty painful, but still don’t rate a hospital admission. And they go to clinics. They don’t need 30 days of Vicodin with refills. They need 3 days of Tylenol 3 with no refills, but they can’t even get that, because of the policy.
That’s just with self-policing. Now it’s going to be even worse.
It does frustrate me that we have drugs that can really, really help with short term acute pain but people have to suffer because of an outside issue. My husband has a hereditary condition that leaves him prone to tooth abcesses. These are awful. They will lay him out in an agony of pain. Antibiotics treat the condition, but they take 3-4 days, and 3-4 days is a long, long time when you’re in acute pain. Now, in the past there were doctors who gave him 30 days of Vicodin, and I agree that that was probably not good practice–he didn’t need that many, so it opens up the door to becoming addicted. But why was prescribing 5 days of Vicodin never a strategy? Why did it go straight to none?
I have no idea why, but I once asked a doctor for a day’s worth of some kind of Rx pain medication following a minor procedure, after which I thought Tylenol would work. He actually said that insurance companies looked askance at one-day Rxs, and that giving me 10 days worth would be better. Maybe economics of scale makes it cheaper. I really have no idea, and am still scratching my head over what is suspicious about a one-day (3 pills) Rx.
I am always scared of laws like this. Ivylad is on some serious narcotic pain meds that unfortunately don’t do much. He’s got nerves tangled up in scar tissue and is in constant pain. All he can hope for is some alleviation…it never goes away.
He’s not an addict. He needs these meds to function.
Kentucky passed a law a few years ago that didn’t place hard limits on doses but laid out guidelines for controlled substance prescribing. The law itself laid out some fairly basic rules but they also required our medical licensing board to come up with its own more comprehensive set of guidelines that would then have the force of law. The result was a bit of a train wreck, since there were now two sets of totally separate guidelines. Our state ACP group hired a health care law firm to merge the two into a single set of guidelines, and they eventually declined to do so because in many places they were outright contradictory.
Now, 95% of these new rules just codified things that responsible prescribers were already doing anyway. But it was rather staggering how many docs, for instance, hadn’t even signed up to access the state’s prescription monitoring system.
Everybody freaked out for a while, but so far it has gone like I expected–since there are so few resources available for enforcement, they use the rules to go after the most egregious offenders, and no well-meaning docs have gotten in trouble for failing to dot the i’s and cross the t’s. So thus far it’s worked out fairly well.
The 100mg morphine equivalent seems reasonable to me. My area has a lot of people on chronic narcs for nonmalignant pain, but very few of them are on more than 40mg/day of hydrocodone or oxycodone. (40 or 60 morphine mg equivalents, respectively).
What I really don’t like is the idea that people with acute pain don’t need narcs for more than three days, and that three months=chronic pain. I had a knee injury last year for which I required pretty regular pain meds for a week or so then very intermittently (1-2x a week, maybe) for about six months. I would have been pretty miserable (and way less productive) if I hadn’t been able to get those meds because my pain didn’t fall neatly into one of those categories.
Legislators setting limits to what medical professionals can prescribe? Yes, that makes perfect sense. I mean, who trusts doctors? And politicians of course know far more about medical matters.
How on earth does such a time limit affect things?
While I agree 100%, it is PRESCRIBED opioids that are at the heart of the current nationwide crisis. Doctors, as a whole, or at least some significant portion of them, are indeed doing something wrong.
I think this is going to have serious negative consequences.
That article is a nice story, but most people cannot quit cold turkey. Opioids are addictive by design.
Chronic pain conditions sap the life out of people. If they have become addicted to opioids because there is no alternative pain relief medication, then Maine needs to provide an alternative. I don’t know if marijuana is available there, but it should be. I have never tried it, but from what I’ve read it is a very good pain reliever. And much better for the human body than addictive opioids (yes, I know it is not perfect).
That woman is 68. Hardly a person who people would consider looking to get “high” off the opioids. She was looking to control her pain. The fact that she could quit cold turkey is great, but not the average scenario.
People will seek out whatever drug they need to fight their pain. Passing a law like this, where honest people will be forced to seek out illegal street drugs is a dangerous way forward.
Older folks who are suffering from chronic pain don’t get “high”. They use the meds to block the pain.
She said she lived for the next pill. How many people are now going to live for their next heroin fix?
Good post doc.
I agree that more MD’s need to be wary of opioids for chronic long term pain. Too many people are addicted- and their doctors know it. It’s just too much trouble to get their patient off, too often.
My wife was on enough morphine daily to kill two regular addicts.
She had degenerative arthritis in the hip. The hip was disintegrating. The pain was getting worse and worse. She needed a total hip replacement. She got it, but she had to wait, in terrible pain, for more than 10 months.
See, she was anemic. Due to an operation 15 years before where part of her stomach was removed, she wasn’t absorbing enough iron. She apparently wasn’t absorbing enough morphine either. She was up nearly 300 mg a day. This was in pill form. She probably could have used a lot less if she injected it. Even at 300 mg, she would still wake up crying from the pain.
I guess you didn’t finish reading the article, then. It’s just about 1/2 through it
Ah,missed that bit. Thanks.
Many current heroin addicts started their opioid addictions with legal prescriptions. Would the new laws prevent someone from falling into addiction in the first place? You don’t ever want to put a patient in the position of living for the next pill.
Specific provision on exceptions, Page 5 of the enacted bill (PDF):
You must have missed it, here’s the direct quote:
But put me in the camp that thinks it’s doctors that should be prescribing things, not legislators.
Tessalon (benzonatate) is neither new or expensive - it was approved by the FDA in 1958 and is available as a very cheap generic.