Overview and a Question
Early next year, the legislature will likely continue efforts to address the rising dysfunction, disability and death from opioid drug abuse. The Senate passed a bill this fall which is under consideration by the House. The Governor has also filed legislation and the House will likely have a bill of its own. Hopefully, we will be able to take the best elements of those bills to craft a final package. Meanwhile, the legislature and the administration are addressing many dimensions of the problem through other legislative vehicles and existing executive powers.
Focusing first on addiction to prescription pain killers, I wanted to pull statistics together and to get your local perceptions on the issue. You can wade through the numbers below, but I’ll offer my summary observations here:
- We face three intertwined problems:
- Casual, episodic youth abuse of pain killers with potentially tragic consequences. Thrill-seeking kids now have easy access to potentially fatal substances.
- Opioid/heroin addiction of young people, whether through a surgical or injury experience or, perhaps more commonly, just through continued risky abuse in a detrimental peer group.
- Older individuals with chronic conditions who may use or abuse pain relievers prescribed to them and perhaps make fatal mistakes using them in combination with other drugs like alcohol and benzodiazepines.
- An additional category of opioid users is cancer patients in hospice settings, where the only real issue is to protect them from pain.
- The problem of episodic youth abuse may be peaking and turning down as awareness builds as to the risks of pills.
- The problem of addiction and overdose among young adults is at its highest level ever and may not have peaked. The harms associated with addiction have been multiplied by the introduction of fentanyl into the illicit markets.
- There is a lot of evidence that doctors are getting the balance between pain control and addiction control wrong and letting too many pills out into the environment, but there are two sides to that story.
Based on what you are seeing and hearing yourself, are doctors you know getting the balance wrong and making pain medication too readily available? If they are getting the balance wrong, there is a second and distinct question: do you feel that the legislature should pass new laws regulating the decisions that doctors make with patients? I’m most interested in personal experiences, but also very interested in any reliable data sources that I should add to the collection below.
You can comment at the end of the article: Feel free to comment without using your full name if you prefer to remain anonymous. I’d very much welcome comments from physicians and other health care professionals.
Opioid Overdose Statistics
Recent data from the Center for Disease Control show that:
- In 2014, more people died in the United States from drug overdoses than in any previous recorded year.
- 47,055 died of drug overdoses — while only approximately 30,000 died in motor vehicle crashes.
- The national age-adjusted rate of drug overdose death more than doubled from 2000 to 2014 — from 6.2 per 100,000 people to 14.7 per 1000 people.
- The age-adjusted death rate in Massachusetts, 19.0 deaths per 100,000, was well above the national average.
- Opioid drugs — drugs that are derived from or act in the same way as opium, for example, heroin, fentanyl and oxycontin — were known to be involved in 61% of overdose deaths.
The breakdown underneath the national totals in the CDC report is as follows:
- The age group with the highest drug overdose rate is persons 45-54 years old, with 28.2 deaths per 100,000. Drug poisonings and suicides are driving an overall rise in mid-life mortality among middle-aged white non-Hispanic men and women (after decades of declining death rates).
- Youth aged 15-24 have a death rate that is considerably lower — 8.6 deaths per 100,000.
- People over 25 accounted for over 90% of the deaths.
- Men have a higher death rate than women — 18.3 vs. 11.1.
- Non-Hispanic whites have a death rate (19.0) that is much greater than the rates for Hispanics (6.7) and non-Hispanic Blacks (10.5).
The CDC notes that:
The 2014 data demonstrate that the United States’ opioid overdose epidemic includes two distinct but interrelated trends: a 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin. . . . [I]llicit fentanyl is often combined with heroin or sold as heroin. Illicit fentanyl might be contributing to recent increases in drug overdose deaths involving heroin. Therefore, increases in illicit fentanyl-associated deaths might represent an emerging and troubling feature of the rise in illicit opioid overdoses that has been driven by heroin.
In Massachusetts, unintentional opioid overdose deaths have occurred in almost every community over the past three years. Opioid overdose deaths, 80% of which are unintentional, have grown by a factor of 8 over the past 25 years. Unintentional opioid deaths roughly doubled from 2000 to 2013. The demographics of opioid deaths in Massachusetts are similar to the national demographics — tilted to towards people who are middle-aged, white and male and more prevalent than motor vehicle deaths — see Tables 18 and 19 in this death analysis from the Department of Public Health. Local anecdotes that I hear as a legislator also point towards a heavy role for fentanyl and fentanyl/heroin combinations in the recent spike in overdose deaths.
Surveys of Substance Use Prevalence
According to the National Survey on Drug Use and Health, the number of people admitting past-month use of pain-relievers has remained fairly stable for the last decade, bouncing around 2% of respondents (actually dropping slightly in 2013). The rate of admitted past-month heroin use was lower, 0.3% among young adults in 2013, but the rate of heroin use use appears to be rising to levels perhaps twice those reported early in the century.
The count of heroin users reported in the survey is a soft guess, likely a significant underestimate — typically survey methods are less likely to reach people whose lives have become chaotic. Alternative measurements of cocaine use prevalence suggested rates far above those detected by surveys in a study I did in the 90s. However, the divergence in trends (between prescription drugs and heroin) is meaningful and consistent with the divergence in trends in the death statistics.
While deaths from prescription drug overdose are higher among middle-aged adults than among young adults, more young adults (18 to 25) admit past month non-medical use of “psychotherapeutics” — the category that includes pain relievers — than older adults: 4.8% as compared to 2.1%. But the young adult rate was lower in 2013 than the rates from 2002 to 2010.
The number of first time users of non-medical psychotherapeutics dropped significantly in 2013 to 1.539 million — the peak year in the past decade was 2003 with 2.456 million initiations. The rate of initiation is a leading indicator, so this drop is encouraging. The 2013 Massachusetts Youth Risk Behavior Survey, administered confidentially in schools, shows drug use flat to down in most categories. However, non-medical use of prescription drugs is still second only to marijuana as measured by life-time experience among high school students (41% vs. 13% vs. single digits for other kinds of drugs).
Also perhaps encouraging are the leveling-off in the rate of persons meeting criteria for dependence on or abuse of pain relievers — see the Household Survey at Figure 7.3 — and the drop in illicit drug dependence among youths aged 12 to 17 (Figure 7.5). This coincides with an increase in the rate of people receiving treatment for pain relievers (Figure 7.9).
One way of reading these data is that, overall, fewer people are initiating abuse of pain relievers and the trend may be positive, but there is an increasingly visible sub-population that is continuing to use, turning to heroin, feeling the need for treatment and overdosing on fentanyl-laced street drugs.
Health Care Events
Treatment data are hard to interpret because drug treatment program admissions reflect both need and availability. Availability may be more stable than need, so stability in treatment admissions may be as much related to limited availability as to need. With that caveat, treatment statistics from the Massachusetts Bureau of Substance Abuse Services, show the following:
- Overall admissions were stable at about 100,000 per year from 2005 through 2014.
- In the same period, heroin admissions rose as a share of overall admissions, from 38.2% to 53.1%, while alcohol and cocaine admissions fell.
- Admissions for opioids other than heroin peaked at 10.9% in 2011 and dropped backed to their 2005 level of under 6% by 2014.
- Youth admissions (under 18) trended slightly down from 2004 to 2012. For most youth (72.2%) marijuana or alcohol was the primary substance of abuse, but 14.8% reported having used heroin in the past year and 33.2% reported having used other opioids in the past year.
- Admissions for older adults (over 55) trended distinctly upward from 2003 to 2012. Alcohol was the primary drug of abuse in 71.4% of the admissions, but 17% were admitted for heroin abuse and 9.2% had used other opiates in the past year.
Emergency room admissions are less constrained by supply and do show increases in the period from 2004 to 2011. Boston-area emergency rooms report to the federal Drug Abuse Warning Network. Emergency room visits in the Boston-Cambridge-Quincy Metropolitan Statistical Area show the following trends:
- Overall, emergency room visits for substance abuse rose 41% from 2004 to 2011 — 35% among persons 21 to 24, 97% among persons 45 to 54.
- The total number of emergency room visits was estimated at 51,845 in 2011 or roughly 1 for every 100 persons in the area (although many visitors may have repeated, so the true share of people with a visit to the emergency room for substance abuse is probably lower).
- Mentions of cocaine use (12,562) were only slightly below heroin mentions (14,057) in 2011; both categories trended upwards from 2004 — cocaine mentions by 34%, heroin mentions by 37%. The 2011 data do not capture the recent spike that has been so much in the news.
- Mentions of opiates/opioids were up 68% in the period, reaching 9,354 in 2011.
- Benzodiazepines (anti-anxiety drugs like valium) were also up 66%, reaching 8,725 in 2011, close behind the pain relievers.
This last finding highlights the risks of polysubstance abuse. Rhode Island’s Strategic Plan on Addiction and Overdose examined the concurrent use of substances resulting in overdose deaths, finding that benzodiazepines were frequently present together with cocaine, heroin and/or fentanyl.
There is little debate as to whether increased prescriptions by doctors of opioids for pain have contributed to addiction and overdoses. I have heard countless stories of people who have received prescriptions for large quantities of narcotics after relatively minor procedures. They are then faced with the question of how to dispose of them. I have a friend whose child got in trouble for bringing to school pills left over from a surgical procedure and attempting to sell them.
In her testimony to Congress on May 14, 2014, the head of National Institute on Drug Abuse, said:
Several factors are likely to have contributed to the severity of the current prescription drug abuse problem. They include drastic increases in the number of prescriptions written and dispensed, greater social acceptability for using medications for different purposes, and aggressive marketing by pharmaceutical companies. These factors together have helped create the broad “environmental availability” of prescription medications in general and opioid analgesics in particular.
The figure below, taken from the same testimony shows opioid prescriptions dispensed by US retail pharmacies almost tripling from 1991 to 2011, although dropping slightly over the last year or two.
To put these quantities in perspective, in 2010 enough opioid pain relievers were sold in the United States to “medicate every American adult with a typical dose of 5 mg of hydrocodone every 4 hours for 1 month.” Put that another way, enough pain relievers were sold to keep 1 in 12 adults medicated on a year round basis. Geographic and demographic variations in prescription rates correlate roughly with overdose death rates.
The Governor’s Working Group on opioids cited a telling statistic from the National Survey on Drug Use and Health in 2013:
Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2012-2013
This chart shows that very few people using pain relievers non-medically got them from strangers or dealers (only 4.3%). Some got them directly from doctors but most got them from friends or relatives who, in turn, in 83.8% of cases, got them from one prescribing doctor. These survey results apply to the whole universe of people who have used opioids in the past year and therefore includes many who use is only casual. Another study reached a different conclusion as to the sources of drugs for people actually diagnosed with opioid abuse or dependence: 79.9% had an opioid prescription of their own prior to their first abuse diagnosis. But either way, the source of abused opioids is prescriptions.
An equally telling statistic from the National Survey is that among the 2.8 million people who used drugs illicitly for the first time in 2013, over 20% started with nonmedical use of prescription drugs, 12.5% with pain relievers — marijuana is the most common first drug, but many people go straight to pills. A further stunning statistic consistent with a perception that there are just too many pills out there accessible to kids — not only opioids, but other abusable psychoactive drugs — was that 12 and 13 year-olds were more likely to admit using pills nonmedically in the past month (1.3%) than marijuana (1.0%) — Figure 2.8 in the National Survey. Another study that the Governor’s working group cited indicates that “[A]dolescent males who participate in sports may have greater access to opioid medication, putting them at greater risk to misuse these controlled substances.”
A CDC analysis in 2012 showed that how widely prescription rates vary across the states, tending to suggest differing approaches to main management. Massachusetts compares as follows:
- Low in its overall prescription rates for opioid pain relievers, ranking 41st in prescriptions compared to populations.
- Low in prescribing high dose pain relievers, ranking 41st.
- High in long-acting, extended-relief opioids like Oxycontin, ranking 8th among the states.
- High in benzodiazepines, ranking 9th among the states.
That CDC analysis concludes:
Factors accounting for the regional variation are unknown. Such wide variations are unlikely to be attributable to underlying differences in the health status of the population. High rates indicate the need to identify prescribing practices that might not appropriately balance pain relief and patient safety.
The Pain Control Movement
As clear as it is that pain medications are a precipitating factor for the surge in addiction, there is also a powerful movement to control pain better. In fact, in section 4305 of the landmark Patient Protection and Affordable Care Act, Congress ordered the Department of Health and Human Services to convene a conference with the following purposes — to:
(A) increase the recognition of pain as a significant public health problem in the United States;
(B) evaluate the adequacy of assessment, diagnosis, treatment, and management of acute and chronic pain in the general population, and in identified racial, ethnic, gender, age, and other demographic groups that may be disproportionately affected by inadequacies in the assess-
ment, diagnosis, treatment, and management of pain;
(C) identify barriers to appropriate pain care;
(D) establish an agenda for action in both the public and private sectors that will reduce such barriers and significantly improve the state of pain care research, education, and clinical care in the United States.
The Institute of Medicine convened a distinguished panel in response to this order. Their report brief dated June 2011, defines pain as a problem affecting 100 million people in the United States and costing $635 billion per year. It uses the same kind of ambitious language used by groups seeking to address drug abuse use, but focuses on pain as the problem:
Pain represents a national challenge. A cultural transformation is necessary to better prevent, assess, treat, and understand pain of all types. Government agencies, healthcare providers, healthcare professional associations, educators, and public and private funders of health care should take the lead in this transformation. Patient advocacy groups also should engage their diverse constituencies.
In comments delivered to the panel, pain patients lamented their treatment as criminals and physicians prescribing opioids complained of unfair scrutiny. The federal panel’s full report spoke of access to opioids for pain as a human right.
A reasonable degree of access to pain medication—such as the stepped approach of the World Health Organization’s Pain Relief Ladder for cancer—has been considered a human right under international law since the 1961 adoption of the U.N. Single Convention on Narcotic Drugs (Lohman et al., 2010; WHO, 2011). Similarly, countries are expected to provide appropriate access to pain management, including opioid medications, under the International Covenant on Economic, Social, and Cultural Rights, which guarantees “the highest attainable standard of physical and mental health” (citation omitted).
The full report does recognize the “conundrum of opioids” as an “underlying principle”, but views it as a manageable problem:
The committee recognizes the serious problem of diversion and abuse of opioid drugs, as well as questions about their long- term usefulness. However, the committee believes that when opioids are used as prescribed and appropriately monitored, they can be safe and effective, especially for acute, postoperative, and procedural pain, as well as for patients near the end of life who desire more pain relief.
The committee viewed opiate abuse as a nuance of pain treatment. Even though the committee devotes a full chapter to pain care and does touch on the issues of diversion and abuse, its recommendations related to pain care focus entirely on removing barriers to treatment, not on reducing abuse. Its overall recommendations seek to encourage greater awareness and treatment of pain as a public health problem. The Massachusetts Pain Initiative is a local organization devoted to those goals which has expressed reservations about both the Senate’s bill and the Governor’s bill that would restrict access to opioids. For more statements and studies on the pain issue, see Drug War Facts.
Consistent with a national effort to treat pain better, the federal government’s hospital care quality survey includes pain management as a metric. Consumers can compare hospitals on a federal website based on the what percentage of patients reported that “their pain was ‘Always’ well controlled”. The pain questions also factor into a federal 1 to 5 star rating system for the patient experience of care in hospitals. In a recent conversation with a hospital administrator, I heard frustration that this system pushes hospitals to use powerful pain medication to get “smiley faces”.
The Governor’s Opioid Working Group, in its June 2015 report, included training for “all practitioners” as to “addiction and safe prescribing practices” as a key strategy. The Massachusetts Medical Society promptly, in August 2015, updated its guidelines for Opioid Therapy and Physician Communication. In October 2015, the Board of Registration in Medicine incorporated these guidelines into new standards of care motivated by the Working Group’s findings.
Summary and Question
Clearly, physicians who are called upon to treat pain face powerful conflicting goals and incentives. Pain is a real problem and addiction is a real problem. Based on what you are seeing and hearing yourself, are doctors getting the balance wrong and making pain medication too readily available? If they are getting the balance wrong, there is a second and distinct question: do you feel that the legislature should pass new laws regulating the decisions that doctors make with patients? I’m most interested in personal experiences, but also very interested in any reliable data sources that I should add to the collection above.
Feel free to comment without using your full name if you prefer to remain anonymous. I’d very much welcome comments from physicians and other health care professionals.
Responses to comments, December 24, 2015
Thanks to all who have weighed in so far — I have read the comments carefully. Here is what I heard:
- A number of people offered examples of receiving much more pain relievers than they needed after simple procedures. It seems clear that there has been a pattern of this. While the need for pain medication is very real in some cases, the pain movement did manage to overshoot, especially when combined with the pressures of satisfaction rating systems and pharmaceutical marketing. The answer to the first question about whether doctors have been getting the balance wrong is “yes, in many instances, but they may be making an adjustment.”
- Other people offered examples of having a hard time getting the pain medications that they legitimately need. It seems clear that this also happens and may happen more in the future. And I hear the point that managing pain and medication can be very complicated and that the idea of “balance” is an oversimplification. It is much harder to judge how often too much medication has been offered in chronic pain cases. This ties broadly to the issue of over treatment generally, very hard to judge — doctors have tools and they may like to use them too much, but those tools can do great good.
- Overall, in this thread of comments, the answer to the second question about whether we should pass new prescription laws is much less clear, but tilts towards “no, don’t interfere in the doctor patient relationship.” I hear some mistrust of doctors (too influenced by big pharma), but more mistrust of government — too likely to put in place clumsy new rules that will help in some cases, but hurt in others.
My sense of the issue is that doctors are under a lot of pressure. Clearly, the Massachusetts Medical Society is responding aggressively with education measures. All too often in the history of drug regulation, by the time we pass new laws, society has already solved the problem in other ways.
Given the current severity of the epidemic and the elevation of public concern, we in the legislature inevitably will pull every lever we can reach, including additional regulation of prescriptions. That is what we always do, for better or for worse — we respond. My goal will be to make sure that the voices of physicians and patients are heard, along with the voices of those who have lost loved ones to addiction, and that the legislation is framed as sensitively as possible to both groups of concerns.
Legislative Progress Update, January 11, 2015
The House is bringing to the floor an updated substance abuse bill. The approach in this bill is very moderate — essentially encouraging doctors to limit prescriptions to seven days, but allowing them latitude to go further if they record the reasons behind their professional judgment to do so. This seems likely a sensitive and realistic approach.
Section 19D. (a) When issuing a prescription for an opiate to an adult patient for the first time, a practitioner shall not issue a prescription for more than a 7-day supply. A practitioner shall not issue an opiate prescription to a minor for more than a 7-day supply at any time and shall discuss with the parent or guardian the risks associated with opiate use.
(b) Notwithstanding subsection (a), if in the professional medical judgment of a practitioner more than a 7-day supply of an opiate is required to stabilize the patient’s emergency medical condition, or the opiate is prescribed for chronic pain management, pain associated with a cancer diagnoses or for palliative care, then the practitioner may issue a prescription for the quantity needed to stabilize the patient’s condition. The condition triggering prescription of an opiate for more than a 7-day supply shall be documented in the patient’s medical record and the practitioner shall indicate that a non-opiate alternative was not appropriate to address the emergency medical condition.
The Senate Chair of the Mental Health and Substance Abuse Committee has commented favorably on the proposal. This more moderate approach is likely to be the way we end up going, but there will be several additional steps of this process before an approach is finalized.
The head of the Massachusetts Medical Society was quoted in the State House News on January 11 as follows:
“I think it’s fair to say we recognize there are too many opioids circulating in the community at large. One of the ways to address that is to take a look at the volume of prescriptions at the front end. We think that looking at a seven-day initial limit as was mentioned in this bill is a reasonable compromise.”
Additional thoughts welcome!
I feel the need to address this situation should be a priority!!
The lives lost to young people is tragic!
Please help in eliminating this occurence, that happens on a regular basis,destroying so many families.
I have had major surgery and twice been injured in bicycling accidents. On those 3 occasions, I was prescribed oxycontin, which helped me get through. I did not become addicted, and I did not misuse the medicine. I strongly feel that prescriptions should not be restricted. Do not make restrictions for all to deal with abuse or misuse by a few. In all 3 cases, I would not have been able to go to a drugstore multiple times to refill small allotments. Do not make limitations that will cause harm to those of us who use medication when necessary and use it wisely.
While we can see there’s a serious problem with drugs, there should be other ways of dealing with the issue. Can such prescriptions be tracked and flagged, to prevent an individual from getting multiple prescriptions from different doctors and providers? What about better access to mental health services? Other options to focus on problem users vs. all users.
Thank you for your consideration.
In my experience the doctors are prescribing the narcotic pain meds even when they’re asked not to. I live with complex congenital orthopedic deformity that requires multiple surgeries, and I never wanted any narcotics, as they make me feel sick. I know myself well in regard to pain management, and I do really well just with ibuprofen or acetaminophen. However, even when I inform nurses and doctors of these fact and ask them not to prescribe me narcotics, they usually insist I take them and prescribe them. Another example is about my daughter. When she was 9, she broke her pinkie and needed a surgery. She was not in pain before or after the surgery, and we were sure to mention it, but they prescribed her a liquid opioid med anyway. We didn’t get it and tossed the Rx. When the patient is not in need of pain med and/or asks not to, they should not prescribe it.
My personal experience involves two knee surgeries with different doctors, 10 and 4 years ago, and two neck and shoulder injuries. In all cases I was not prescribed sufficient pain medication to prevent or lessen the pain immediately following the surgery (only 2-3 days of meds are needed) or to ease the pain after injuries. I was also not given the option of trying a different medication when the ones prescribed (percocet, vicodin, oxycodone) had little to no effect on me. I called the doctor’s office crying the night after surgery and begged them to let me try something different and was told there was nothing else to do except try one the counter drugs (which did not help). They would not even prescribe a single pill of ambient or another drug to help me sleep, and I was up all night bawling my eyes out. It felt like we live in a Puritan state where we are supposed to tolerate such suffering rather than be given a drug to ease it.
I needed a third knee surgery this past spring and went to a specialist in California. I explained that the meds I had tried before did not work for me. They had a whole different approach to pain management. They gave me a shot of keterolac in the knee after surgery to numb it, and gave me additional oral doses for p[ain to cover the next 1.5 days until I was seen again as a follow up. I was also given several days of dialaudid, which I only had to use at night, the first three nights. Finally, I was given five ambient pills, but again, I only needed three and never used the others. It was like night and day. The philosophy was to “get ahead of the pain” instead of waiting until I am in agony to try something (or deny giving it to me!).
I get that addiction is a problem, but the answer does not lie in denying people temporary pain relief associated with surgery or injury. Perhaps part of the answer is for the doctor to limit the amount prescribed and refer a patient who needs more to a pain specialist who is subject to additional government oversight. Also, making it easy for a patient to get rid of unused meds by returning them to the pharmacy or doctor’s office for disposal, rather than having to to to a police station.
I continue to be amazed and appreciative of your efforts to inform and consult with your constituency. You have already received many thoughtful and knowledgeable comments. My initial reaction is that the legislature, once again, is trying to solve an obvious social problem with fast-acting, simplistic answers that will create more problems than it fixes. As stated in all the comments, there are a large number of issues here, each of them requiring study groups and thoughtful legislation if needed. We may need to put more pressure on the medical community to police its own, but I am totally against the legislature putting restrictions on the medical community. I have been a nurse for over forty years. In the early days, pain medication was given out very carefully and primarily to make sure that patients were able to carry out functions needed to get well, like walking, coughing, etc. after surgery. We have now progressed to the point where there seems to be an expectation that there should be no pain. The smiley face pain charts in the hospitals that I saw with my own family members are bizarre and the fact that hospital ratings would have anything to do with that is crazy. The current crisis gives us an opportunity to have these conversations and change many things, none of which will need legislation. Modern medicine has also allowed individuals to live longer but also have incredible pain. Nothing should happen to make those individuals’ lives worse than they already are. All of us have the opportunity to tear up pain med prescriptions when they are given to us. I just wait to fill them, because I don’t want to spend the money, and then usually don’t need them. Pharmacists need to be in on this discussion, because the prescriptions could easily read: five of whatever with a specific number of refills so that there aren’t extra pills laying around. I don’t know very many people who throw those pills away, thinking that they might need them later, so there is a lot of medication laying around. Medicines should NEVER be disposed of in any water supply. They are easily broken up and thrown in the trash in the communities that incinerate the trash. I haven’t read much on medicines in trash that go to a landfill, but it sounds like a future nightmare. Instructions included with a prescription on how to dispose of the remainder of the medication would cost some money but sounds like it would be worthwhile considering the number of comments on it. The community collections of medications are complicated and expensive, and I’m guessing that it would be a nightmare for most pharmacies to have to take back the medicines. It is just too large of a topic for this comment but the lack of mental health services is a huge piece of this puzzle. Our health insurance industry loves to hand out medicine for everything, instead of actually taking the time and discussion necessary to really address the problem. Ask any mental health professional whether there are enough mental health beds or therapists to assist with these problems and they will tell you, “NO!” Thanks again for your hard work on this and other legislation.
A lot has been covered in your write up and the emails that I won’t repeat. One thing I read today is that since there is no system for informing doctors if their patient has had treatment for an opioid overdose, they often (more than 80% in one sample) continue to prescribe opiates to these patients. This could be addressed by additional legislation/regulatory changes. Also, the few times I’ve had a patient who abused the meds I prescribed (in my case stimulants since I don’t prescribe opioids) there is no way,without a patient’s signed consent form which you’re not likely to have, to warn other doctors in the patient’s pharmacy profile/Prescription Monitoring Program that an alert has been raised. Different pharmacies handle it quite differently- some legislative/regulatory clarity here could be helpful too.
Good points about the systems, Naomi. Thank you. I will pass them on.
I have been taking opioid pain medication for about sixteen years . With out it I would have ended my life myself . With out it I would not have been able to take care of myself or my children. Doctors should not have to fear treating people in pain.we need new medicines to treat pain not polititions making medical decisions for us.
New meds may be a big part of the solution.
1. When people don’t have access to primary care physicians, they hop from one ER to another trying to get opioids and ER doctors can’t refer them back to anyone so they give in and give them pills.
2. When hospitals must make money, ER doctors get bad customer reviews if they don’t give people opioids even if the people would be just as fine with something like Motrin.
3. Cities like Pittsfield don’t have enough police on the force to properly counter the influx of drugs. Heroine is now cheaper than many prescription drugs and it is easy to sell it on under-policed streets.
Yes, I think this customer review issue is an important part of the problem. Customer feedback is terribly important, but how it is framed for pain medication is something that needs attention.
Senator we all appreciate your caring efforts, i agree with your position and God speed to you and us all in getting it passed.
Thank you so much Senator for addressing this issue here, where people can chime in. I need to start by saying that I have several compound chronic pain conditions, and am over 50, with many years of all therapies. I think it would be disastrous if doctors had their hands tied when it comes to chronic sufferers. I do believe that some of my conditions are derived from childhood sexual abuse, and that legislature could never tackle controlling something like that — instead, it’s more visible to tackle the doctors.
If I had no access to pain medication I would most certainly end my life at some point. I get drug tested every 2 months to ensure that I’m not abusing it, + to be sure that I’m not selling it. Doctors are not to blame here. **How ’bout a huge movement to help people who have no idea why they feel the need to an escape ??? It’s a sad reflection: people needing a license to fish, but not one to raise children. Again…doctors are not our parents and are not to blame for this epidemic. I’ve lost several friends who chose to use IV heroin, and some of them were never even claimed at the morgue. My particular friends didn’t have a very good family-base though I understand so many do/did. The focus should be on parenting and family. (But good luck with that!!). Please, please don’t take away the ability of responsible people, responsible doctors, who are trying to keep good people above water.
Thank you again Senator and keep up the great work 🙂
Thank you NTD — As I listen on this issue, I am moved more and more by the need to ask just the question you are asking: Why are people continuing to take these drugs? In some cases, it is chronic physical pain. In others, it is chronic emotional pain and hopelessness — putting our attention on those underlying problems may be most important.
I have been a chronic pain patient for a decade. I am 68 years old. When I first went to a hospital pain clinic 7 years ago, I was put through rigorous tests and procedures that did not involve opiates- for perhaps 3 or 4 years. Only when these other measures proved inadequate for me to control my pain to a point where I could continue to work and support my family, was I given opiates. Small doses at first, gradually increasing to the point where I am now. I have had the same prescription for three years and it works well. i do not need anything stronger for daily use. I have never run into these doctors who give out painkillers indiscriminately. I keep my drugs under lock and key. I do not use alcohol or other recreational drugs. My pain clinic is aware of all the drugs I take and is the only source of pain medication I am allowed to have, even post surgery. They were involved in my care when I had my three knee replacements, hip replacements, rectal prolapse and intestinal resection. Not to mention the surgeries I had to implant the neurostimulator that also serves to control my pain. Perhaps it is because I went to professionals that I have had such success, and I do consider myself a success. I am not an addict, although I am physically dependent on the medication in that I would get sick if they were suddenly stopped. But I feel no craving and I don’t exceed my dosage. The most important thing about being maintained on the opiates is that I can work as a crisis counselor and grant writer for a homeless organization. If my pain weren’t controlled I wouldn’t be able to get out of bed. I would love to continue to have a life, just like everyone else. I would be happy to testify at any hearing or speak on the topic if it would help.
Sounds like you are doing everything right.
The law is not intended to make pain management harder in chronic situations and I don’t believe it will.
As I get older – I’m 68 – I think about a time when I might move from my current address to something smaller. This would probably be a move to a smaller town or area away from my pain clinic where I would have to rely on the services of a PCP. I would bring my record etc from the pain clinic and make sure they were in touch. But if you make it so that a regular doctor could not prescribe my medication, then I am stuck in my current address regardless of whether I can make the stairs to the second floor- a frightening thought. You guys could really ruin my life. Please see my previous comment.
I think the rule is intended to preserve the latitude physicians need to care for chronic pain.
I’d be very concerned if we didn’t do that.
Who will monitor and insure compliance? In recent months, we have witnessed nurses working in healthcare without the proper licensing or credentials! EMT and Paramedica toiling without updated credentials and worse yet, the failure of cities and towns emergency responders meeting established critical response times! Without the teeth of strict compliance, this is just mush!
I think that doctors take the law seriously because their livelihood depends on avoiding legal complications.
Stick to running the state and stay out of the medical profession. The Commonwealth can not even take care of the children under it’s care right now and has deficit – people will always abuse something
I agree that we should be careful about what we take on. This is a relatively modest step.
Any opiate prescription should be documented in a universal data base, available to doctors, pharmacies, and regulators, to prevent individuals from “shopping around” for a doctor who will, unknowingly perhaps, fill that prescription without knowing that person’s medical history.
Soooo… the only real purpose of this law is to encourage practitioners to issue only 7 day scripts, but if they think they need more than 7 they need to additionally document it. On the face of it this seems like reasonable best practice, but I question why this [[needs]] to be a law.
I just switched insurance coverage and have been without my blood pressure meds for about 2 weeks while they straighten out bureaucratic stuff. I shudder to think what this would be like with the legal aspect to wrangle with.
Once again, I will suggest the solution to these problem is education, not legislation and urge you to “Just Say No” to this law.
I agree that education and culture change is the hear of it. But law making can be part of that process.
The state should improve the tools it provides to physicians to monitor opioid use. The Department of Public Health’s Online Prescription Monitoring Program website is very useful. It allows physicians to look to see what opioid prescriptions the patient has filled within the past year. However, there is a delay in data transfer. One of my patients filled a prescription on 1/2/2016, and the data still aren’t in the database. The information should be transferred overnight.
Definitely an area for improvement!
Thanks Will for taking such a measured and thoughfull approach to this complex problem.
It is noteworthy in your reprt that the vast majority of diverion occurs between friends and family from medication obtained from a single doctor. Many doctors now require patients to come in for random pill counts to try to eliminate diversion, but this is quite time consuming for already very oveworked doctors and staff, difficult for some patients, and can be gamed once people are aware of the process. As you noted there has been a drop in the past 2 years as doctors strive to find a balance between treating pain and ensuring prooper use of medications. In the end,however, doctors can not control what people do with the medication that is prescribed. Patients also bear equal responsibilty for using medication responsibly. (Perhaps there should be a law about the transfer of controlled sunstances to friends and family ?)
Doctors are not omnicient and and are not the police or the DEA.. There is a price that is paid for the increased vigilence of the medical community. Every minute that we spend on opiod monitoring is a minute that we take away from some other task that may be equally important.
My only suggestion would be that improved communication between health care insitutions doctors, pharamies, mental health providers. Primary care doctors should recieve electronic notification when our patients fill prescriptions for controled substances -The state precription monitory progran is good – but it still takes 5 minutes to go to a website- log on remember a pasword, enter the patient information. The state should mandate that all major electronic medical record systems “talk” to each other- so that when a patient is seen at another hosptals ER with an injury and needs pain medication doctors can find out in real time what test were donne and what medication was prescribed.
HIPPA – the law which regulates privacy-specifically states that communication amongst health care providers needed for that care of the patient should not be impeded. However fear of being accused of violating HIPPA ( which is very expensive ) definately impedes communication needed to properly care for patients with chronic pain, substance abuse – as well as many others.
Many people who suffer from chronic pain also suffer from mental illness. (this can be caused by the pain or be independent)The very high wall that is in placed between mental and physical health providers makes coordination of care for these patients extremely difficult.
Many non opiod medications used for nerve ( neuropathic pain ) are also used for teatment of anxiety, deprssion, and mood disorders. Mental health providers are even more overbudened than primary care doctors and often have neither the time nor the inclination to work as a team on issues of pain control. The fact that we have segregated mental health care from the rest of health care exacerbates this problem. Many patients must obtain their care from community mental health centers which are very overburdoned. Communication is virtually impossible- hence optimizing most patient’s treatment is a daunting task.
Thanks again Will for taking the time to understand the complexity of this issue and for supporting a reasoned approach to a very difficult problem.
Thanks for these thoughts, Barry. Your point about systems integration and communication is very well taken. I hope we are able to improve this — your point resonates very much with Dr. Meyer’s point below.
BTW, anyone giving pain meds to a friend or family member is committing a felony — it’s just so private that it is not enforceable.
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