Arbitrarily Reducing Opioids

Payers, legislators, and healthcare systems are implementing limits on how many pills may be dispensed to people with pain in an effort to curb the opioid crisis.

CVS announced this past September they would limit the number of pills new patients with acute pain can obtain to a seven-day supply.

Last July, Maine passed legislation limiting new prescriptions for opioids to 100 morphine milligram equivalents per day for most patients.

The giant prescription benefits manager, Express Scripts, began a program last September limiting people with new opioid prescriptions to a seven-day supply, not to exceed 200 mg per day.

When it published its Guideline for Prescribing Opioids for Chronic Pain in March of 2016, the CDC believed reducing the supply of opioids would lessen the potential for diverting drugs and decrease the number of drug overdoses. However, as physicians have implemented the CDC’s recommendation on dose limits, the country has actually seen a dramatic increase in opioid overdoses.

“I Refuse to Go on Permanent Disability” 

On a daily basis, I receive emails from people who suffer from pain, and I also hear from their loved ones. Larry W. is an example of someone who contacted me to let me know how the CDC guideline has affected him. He wrote, “[I] need help. I am 61 [and] hoped to work to age 70. I take opiates [be]cause I am a farm worker….”

He continued, “I refuse to go on permanent disability. I want to work. It is impossible to put in a full day on what they were giving me as it was not enough and now they are detoxing me so being able to sleep and eat is my current problem. I cannot keep strong enough to feed the cattle.”

Larry’s situation is not uncommon. In fact, he is a poster child for what is wrong with a one-size-fits-all approach to reducing the amount of opioids a person is prescribed.

His email continues, “I am a cripple to say the least but opiates helped me to live a normal life.” He then says that suicide enters his thoughts daily, although he says he wants to live.

Larry’s challenges are typical of those faced by people with pain. Intermountain Healthcare (IHC) is a nationally recognized quality health care system in Utah and Idaho. In an effort to combat the opioid crisis, IHC has set a goal of reducing the number of pills its providers prescribe by 40 percent within a year.

Harming Millions of People in Pain Through Good Intentions

Setting an arbitrary goal to reduce the number of opioids that are prescribed is misguided. Plainly, this approach can cause harm for Larry and millions of others, forcing some of them to turn to the streets where they may encounter illicit drugs such as fentanyl, carfentanil, or heroin that are more lethal than prescription opioids.

As Pain Medicine News reported, the opioid crisis continues to put pressure on physicians (see my recent blog) and diminish their ability to practice medicine. However, patients bear the brunt of the pain.

Here is an email I received recently from Damaris R., the family member of a pain patient whose opioids were reduced. I’ve edited the email for length and clarity:

“I lost my mother this past spring, and her story is tragic. She suffered from severe osteoarthritis as well as other degenerative issues. For thirteen years, she was on an ungodly amount of pain medication. After surgery, they cut her pain medication to less than half of what she had been taking prior to her hip replacement. I sat with her feeling absolutely useless. Her screams were so loud they could be heard from one end of the unit to the other. This went on for weeks. To have witnessed all that happened to my mother was more than any daughter should ever have to see.”

Larry and Damaris’s emails, along with so many others that I receive, make it clear that good intentions by policymakers are not enough. Reducing the supply of opioids may cut down on the possibility of diversion. But the amount of human suffering caused by arbitrarily reducing opioid prescription must also be considered.

I remain convinced that it is possible to solve the opioid crisis while providing compassionate treatment to those who benefit from opioids. Similarly, it is possible to minimize diversion while also providing safe and reasonable care. Ultimately, we need to replace opioids as we know them today with safer and more effective analgesics.