- Clinicians are expressing concern that new guidelines for opioid prescriptions are pushing some former patients toward illegal drugs.
After moving back to Oklahoma to care for his ailing mother, Dave became an unlikely victim of circumstance when he suffered an injury from which he would never fully recover. Despite a two decade-long track record of responsible opioid use authorized by his former physician, Dave was instructed to gradually reduce his dose if he had any hope of continuing to acquire the medicine that provided him the relief he so desperately needed.
While Dave is now able to supplement his opioids with medical cannabis thanks to last year’s passage of State Question 788, he still does not experience the degree of relief he once had.
“I get a little depressed about it every now and then, but you know, compared to a lot of people, my life’s not that bad,” he said.
Dave is among the more fortunate patients who have fallen under guidelines established by the Centers for Disease Control and Prevention (CDC). The non-mandatory guidelines, originally authored as a means to assist physicians in prescribing opioids in a manner that balances safety with efficacy, have been reinterpreted by pharmacies, insurance companies and law enforcement alike as commandments, making it increasingly more difficult for patients to acquire their medications.
These regulatory efforts are part of the attempt to solve the national opioid crisis. Government officials and reporters alike often latch on to the CDC report ranking Oklahoma sixth in the nation regarding the number of opioids dispensed per capita. There is also the latest data published by the National Institute on Drug Abuse (NIDA) reporting 444 opioid-related deaths in Oklahoma in 2016. Of those, 322 — equivalent to 11.6 deaths per 100,000 persons — were attributed to prescription opioids according to the CDC. In addition, the CDC revealed a 14.3 percent increase in heroin overdoses in 2016 and 2017.
With statistics like these, it is no wonder government officials are sounding the alarm. However, a closer look at the data paints an entirely different picture. Although Oklahoma is responsible for dispensing more opioids than 43 states, it came in just behind Maine as the state with the second-greatest reduction in prescription opioid-related deaths from 2016 to 2017.
According to a study published by the QVIA Institute for Human Data Science Study, death rates attributed to prescription opioids did not correlate with a decrease in opioid prescriptions, a measure mandated by the Drug Enforcement Agency (DEA) in an attempt to counteract the epidemic. What the trends are showing, however, is a decline in prescription opioids dispensed being met with a rapid increase in illicit overdoses. On a national level, the CDC states that over 50 percent of opioid-related deaths are attributed to illicit opioids, the majority involving fentanyl. In Oklahoma, prescription opioids are attributed to significantly more deaths than their illicit counterparts, though the trends are beginning to reverse. Fortunately, they have yet to mirror those on record at the national level.
A fatality can be considered opioid-related even if the opioid was not the cause of death, so long as it was present in the individual’s system at the time of death. Intentional overdoses can also be included. A survey from Center for Behavioral Health Statistics and Quality (CBHSQ) indicates most prescription opioid users did not obtain the medications legally, suggesting many individuals whose deaths are categorized as prescription opioid-related are unlikely to be in possession of a valid prescription. However, legally compliant patients are the ones who are left to suffer the consequences of regulatory actions.
Street drugsLawrence Pasternack, philosophy professor at Oklahoma State University, told the story of a friend who injured his back in an accidental motor vehicle collision. Despite the successful completion of a physical therapy regimen, the pain persisted. After his doctor refused to prescribe any more opioids, he decided to take matters into his own hands.
“He started to buy illegal opioids,” Pasternack said. “And then one day, the person he was buying illegal opioids from said, ‘Try this. Snort some heroin.’ My friend became a junkie. For five years of his life, he was a heroin addict.”
It is a story that is becoming all too familiar; patients with doctors unwilling to continue prescribing effective doses often find themselves turning to the black market to acquire substances similar to the ones they once used.
“That’s when the mortality numbers really pick up,” Pasternack said.
S. Blake Kelly, a family physician who has been practicing pain management for 15 years in Oklahoma City, estimates he sees roughly one patient each week that gives him cause for concern.
“I feel pressured that if I don’t get this patient some relief, I’m concerned that they could go down that road,” he said.
Rafael Justiz, a board-certified anesthesiologist with certification in interventional pain management, is a member of Oklahoma Pain Society’s (OPS) board of directors. While he does not have to deal with suicidal patients on a daily basis, he says it is not uncommon for him to see patients who admit they have considered taking their own lives.
Physicians attempting to avoid the hassle and potential scrutiny that comes with writing opioid scripts are actively cutting back, often referring patients to pain management specialists. The clinics willing to handle these cases are then left with an influx of patients, many of them still unable to obtain the care they need.
Recent passage of Senate Bill 1446 officially capped a patient’s dosage at a maximum of 100 milligram morphine equivalents (MMEs), with the exception of certain outlined circumstances.
“I don’t think you can put a number on what we can prescribe because we’re not numbers. Every individual is different,” Kelly said. “If it looks like I need to titrate their medication above 100, I am very uncomfortable doing that in today’s environment because I’m concerned that I will be viewed as a bad doctor, a reckless doctor.”
Like Kelly, many physicians actively avoid attaching themselves to the stigma that often accompanies writing prescriptions in higher doses, which can attract unnecessary attention from DEA.
“Change is sometimes difficult, and this was certainly a seismic change,” Oklahoma attorney general Mike Hunter said. “We intend to look at fine-tuning. We intend to look at clarification with regard to the legislation that was passed last year.”
There are effective alternatives to opioid medication, but insurance companies are not making the lives of these patients or their physicians any easier.
“It’s like pulling teeth out of these insurance companies to get things done,” Justiz said.
When patients’ therapies are approved, they’re often left with a deductible they’re unable to afford.
“Ultimately how that patient is treated is going to be determined by that insurance company. The more expensive the therapy is, the more difficult they’re going to make it,” Kelly said. “They will cover whatever is the cheapest pain medicine and most addictive.”
While law enforcement officials and government legislators are busy cracking down on prescription opioids, leaving responsible patients and their doctors holding the short end of the stick, the real opioid crisis — an epidemic resulting from illicit use and subsequent overdose — is worsening.
“The pendulum has swung way too far in the opposite direction,” Pasternack said. “We need to find our way back to some appropriate middle ground.”