New pain-management rules leave patients hurting

Over the last several months, an effort in Washington to curb a steep rise in prescription-drug overdose deaths — the most ambitious crackdown in the nation — has prompted a number of doctors and clinics to stop taking new chronic-pain patients on opiates, and in some cases to cut off current pain patients.

The rules don't take effect until Jan. 1 but already, many doctors say they will mean a lot of work, requiring them to gather records, check emergency-room reports, sign pain contracts with patients and arrange consultations as they try to assess an invisible affliction.

For now, the effort has engendered more questions than answers.

Are doctors simply using the new law as an excuse to dump pain patients, who can be needy and demanding — and, in some cases, addicted?

Will the new rules cut down on overdose deaths — or just make life unbearable for the many patients who are legitimately hurting?

In the South Puget Sound area, a University of Washington Medicine neighborhood clinic stopped taking new chronic-pain patients on opiates about two months ago, after patients flooded in, saying their doctors had cut them off.

"A lot of it is because other providers have stopped doing it," said Dr. Peter McGough, chief medical officer for UW Medicine's Neighborhood Clinics. "I think there's been a fair amount of patient abandonment going on."

McGough calls the new law and rules helpful and important, saying many pain patients weren't previously well managed.

"That said, a lot of physicians are saying it's more trouble than it's worth, so I'm just going to send my patients away."

The swift reaction by doctors and clinics to the new rules has startled even critics who expected some negative fallout for patients.

"We did not see coming that entire hospitals, ERs and clinics would have anti-opioid policies coming down the pike; we didn't see that coming," said Elin Björling, Washington state policy specialist for the American Pain Foundation, a patient-advocacy group.

full http://seattletimes.nwsource.com/html/localnews/2016035307_pain28m.html

That is ridiculous! Sucks pretty bad for us CP patients...

You think someone on CP meds can just stop like that? Even if they make it thru WD, they still have to deal with the pain they had in first place. Putting Drs in the position of letting people suffer cause they dont want to lose their practice is cruel.

All this will succeed in doing is sending more people to the street looking for smack. They might look for pills first, but once they go broke from spending their money on pills, they quickly realize they can get more with H for their money. It's the same thing when they make pills "unabusable". When I was slinging, I usually asked newcomers about their use history, and alot of them were coming because of the new Oxy formula or they realized they could stay well for half the money as opposed to their pills.

sucks for ppl with actual chronic pain that NEED CII opiates like oxycodone, dilaudid ect because until science comes up with better pain meds that are less addictive, opiates are it! the gold standard for pain relief. practically everything pain med wise is compared to morphine in terms of analgesic activity. I know there are trials for crazy new pain meds, like one derived from puffer fish venom and so on, but that science is years possibly decades away, and until a new class of painkillers come out, opiates are the go to. There needs to be control but too much control makes it hard for people without resources to get the help they need.

Am I missing something here? All I see is that the government is going to make chronic pain patients, and the doctors who treat them for chronic pain, jump through more hoops to keep their arrangement going. I think that's perfectly fair, so long as the hoops are truly effective at letting almost all legitimate pain patients through, and almost no recreational users or would-be sellers.

My school had a presentation by a pain doctor. He made every patient of his sign a contract:
* They were to produce documentation from their primary doctor of a diagnosis that regularly produces severe chronic pain, and documentation that pain control had failed on more conservative measures like lighter drugs and lifestyle changes, before any scripts would be written.
* They were to hand over the paperwork from any ER visit in the country to the pain doc.
* They were randomly drug tested, right down to specific opiate/-oid metabolites and their levels. Everything the pain doc scripted had better show up. Nothing the pain doc didn't script had better show up.
* They were to bring their pill bottle to every visit, and were subject to pill counts.
* They were to report to the pain doc every other visit to a doctor that involved the scripting of scheduled substances.
* They were to make every effort to return to their baseline level of activity before the chronic pain became severe. The pain doc was not there to help anyone stay on disability, veg out on the couch and take bong hits.
* If they lost their script, too fucking bad. This pain doc replaced only one lost script in his career, and that was after the patient produced a document from the fire marshal stating that all the contents of his house were destroyed by fire.

Each patient signed the contract with the understanding that if he was caught breaking any of these rules, the pain doc would refuse any and all further treatment, effective immediately.

This pain doc made an audio recording of every patient encounter, and stored them encrypted on a computer whose location was known only to him. There was no misquoting him in court. He documented copiously. This doctor claims he was sued regularly, but considered that par for the course in his line of work (people in constant pain are very litigious!), and never once lost, because his ducks were always in order and he never let his guard down.

I really do think that it is in the public good for opiates/-oids to be difficult to acquire. They are a class of drugs that most human beings are not capable of using in moderation, when used primarily for their mental effects. So great is their allure that they fetch a high price on the black market, which is another temptation to those who are in poor financial shape. Opiate addiction is a black hole that's not possible for most people to ever fully escape from, and the brain of someone who has been in opiate addiction is a permanently changed one ("You can check out any time you like, but you can never leave.") That said, opiates/-oids are truly the best thing for many pain syndromes, and people who truly have these syndromes in the opinion of a competent physician, and are willing to agree not to abuse or sell the drugs, should have access to them.

I think doctors who've shuttered their practices or taken opiates off the menu in response to these new legal hoops are either chickenshit or lazy, instead of compassionate. Doctors already have a lot of paperwork to file and documentation to submit, so what's a bit more? Come on! Yeah, I can see how some of them might assume that the government is out to nail them with these new rules. But this is kind of like the cheating spouse who accuses his/her partner of cheating: if you're already playing by the rules and intend to continue doing so, what's there to be paranoid about? Makes me think a lot of these practitioners know that they're a little looser handed with narc scripts than the government would like them to be, and know that their ways wouldn't pass muster under the new laws.

^But MDAO, are all opiates created equal? Should dihydrocodine be protected as much as oxycodone or morphine? I think just making access easier to a few basic drugs may make the desire for the harder drugs go down substantially.

^ Granted. I don't see a problem having a two-tiered system, where things like codeine and tramadol can be scripted (even chronically) without the extra paperwork and watchdog-work. This is like places where beverages with <4% alcohol can be sold in convenience stores and supermarkets, but anything stronger only at state-run stores with limited locations and hours. I believe such places have actually seen lower rates of alcohol abuse than jurisdictions where all alcohol is hard to acquire.

I don't support codeine being made OTC again in the Anglophone countries that have made it prescription-only. At least in these cultures, widespread use has always been a problem when it's been so available.

I think recreational opiates should be distributed in clinical settings, with minimal restrictions. They are more than just pain medicine!

Humm benifits and downs.. sad most all threads are about opioids. kinda scary if you ask me.

Yes this happened to me recently dosent even dent opiate abuse...on to the boi. Found a compassionate doc again thank god.

I go to a pain clinic where pretty much all of the above are in place and I think it's a good thing. As someone with addiction history (and a few track marks) I would normally (and did) get treated like shit by my past PM doctors. The current doc I see is great, and because I pass my urine tests and whatnot, he knows I'm not fucking around with my medication.

I find it hard to argue with this - remember, they are only talking about chronic pain patients, this will not significantly affect those dealing with accute and post-surgical pain.

MyDoorsAreOpen said:

I really do think that it is in the public good for opiates/-oids to be difficult to acquire. They are a class of drugs that most human beings are not capable of using in moderation, when used primarily for their mental effects. So great is their allure that they fetch a high price on the black market, which is another temptation to those who are in poor financial shape.

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I completely disagree on that. When I was given unlimited access to heroin (I could do upto 3g a day if wanted, but rarely did), I was easily able to control myself. Went to work every, paid my bills, never broke the law(except for using). It wasnt until I lost my job and couldn't afford both using and living expenses that I got myself in trouble. And when I went on FREE methadone maintenance, I resumed a normal life; noone being the wiser.
That's why people who make good money (lawyers, doctors, etc) get away with their habit; cause they can afford it. It's not until people start living the broke/homeless lifestyle trying to keep up with their habits that they end up in trouble.
Also, alot of users have legitamate pain but have a history of abuse and it's their only choice to buy on the st.

Nobody should be restricting what mentally fit (can reasonably determine risk and actions) adults can ingest or acquire. Opioids and all other drugs should be available to any adult with informed consent (ensure the person wanting the drug is aware of the risks associated with recreational or even medical use, then their fate is ENTIRELY within their own hands). Of course, opioids when they are in limited supply should be prioritized to those with medicinal needs. Also give the recreational users naloxone.

The nanny state of government telling us what we can and can't use and for what purposes is archaic and outdated.

Chronic addicts should be given the option of maintenance to give them a stable life and lower crime. It's a lot cheaper than courts, prisons, extra police, hospitalizations over overdosing and AIDS and Hepatitis from improper IV use, etc. Some places in Europe maintain addicts for life.

At the very least, decriminalize the cultivation of Papaver Somniferum for personal consumption!

A post full of libertarian righteous indignation citing the social welfare states of Europe? I think my irony meter just broke. If a "nanny state" shouldn't have the power to tell you what you can buy and put in your body, then it shouldn't have a taxpayer-funded teat for takers of that liberty to suckle on when they regret their decision. Conversely, he who pays the piper calls the tune. If a government offers goods and services above and beyond basic human rights, it has the sole right to say who is entitled to them, and what procedures are necessary for qualifying.

Timland said:

Nobody should be restricting what mentally fit (can reasonably determine risk and actions) adults can ingest or acquire.

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By this logic you'd be perfectly cool with the most sociopathic degenerate guy in your town being willing and able to possess an atom bomb or pandemic specimen, no? Society as a whole has more to lose than gain by making opiates freely available in unlimited amounts to all adults, and as such, has no incentive to do so. That's the crux of my argument.

Although I'm aware of their existence, I've never been to any European country that has state-supplied maintenance opiates for addicts, and I've never studied the phenomenon in detail. Still, I would guess most or all of these policies are a far cry from opiates being freely available to all adults. I would venture a guess there are still plenty of bureaucratic hoops to jump through to get into such programs, and these programs are used as a last resort for addicts who've failed repeated attempts to get sober other ways, so that no one gets the message that such programs are the government's blessing to go out and become an opiate addict.

From my experience both in clinical and social settings, opiates, especially heroin, have an unmatched power to make people mind-bogglingly selfish, changing their priorities in life dramatically and to a large extent permanently. Even if such a person is able to maintain their habit without any unlawful or antisocial behavior, and lives in a state of endless bliss, the pain their friends and family suffer from seeing them turn into a ghost of their former selves isn't something I would wish upon my worst enemy. Does this happen to all? No. But in my experience, it happens to most.

I agree with you that criminalizing opiate use isn't the answer. But nor is making it easier to acquire and maintain opiate habits. Governments (and private institutions) would be best served by researching therapies like Ibogaine, which appear to offer some hope for a cure to opiate addiction. Once these addictions can be cheaply and reliably cured, rather than remaining nigh-on irreversible, only then would I be sold on the idea of making these drugs easier to acquire.

I'd like to offer up one more unpopular opinion here. I call into question the assumption, implicit in a lot of posts about drug policy, that all recreational drugs deserve equal status in the eyes of the law. I think each drug and class of drugs needs to be judged and legislated on its own merits, with restrictions on some of them loosened much more than others. Just because they're all presently "on that side of the fence" doesn't mean they have anything in common in terms of their potential risks and benefits, both to the individual and to society.

Yeah damn that constitution -- that useless libertarian righteous indignation.

The U.S. seemed to do just fine when opium and its derivatives were unregulated and uncontrolled. Addicts stuck to the opium dens. The only reason it was made illegal, same reason marijuana was made illegal, xenophobic fear of non-whites. In this case the Asians, in Marijuana's case the hispanics.

I see no reason to control opiates and opioids except to ration them during shortages to those who need them, and prevent minors from using them without a medical reason -- and I never will. Of course, if people were allowed to cultivate a flower on their own property - Papaver Somniferum - and use it as they please there wouldn't be as much demand for semi-synthetic opiates and fully-synthetic opioids.

The tighter pharmaceutical grade opioids are controlled, the more the cartels and other unsavory groups profit. When Florida shut down the so-called "pill mills" heroin dealers got a surge of new clients. Personally, I'd rather my fellow countrypersons make money off recreational drug use than some foreign entity that is using the money to buy weapons and slaughter their own people.

In a century people will look back in shock and ask "Wow people weren't allowed to buy any drug they wanted because of statists voting to keep it that way?" Much like we look back now on the absurdities of hyperstatism of the early 1900s.

If family/friends cannot accept that one person gets their pursuit of happiness from ingestion of a drug then that is their problem -- not the user's.

True liberty comes with Darwinism, like it or not. I am dependent and addicted, and it is nobody's fault but my own -- not my dealer not the doctors that write prescriptions for them and not the websites that sell them to me. I will acquire the drugs that give me balance even if its a death penalty offense to possess them illegally. I budget and when I can't afford my drugs I withdraw. I harm nobody with my addiction. I want government and authoritarians to GTFO my life and leave me be and stop placing boulders in my path. I am blessed that the opioid I use presently is unscheduled -- but I KNOW it will be scheduled someday. That's when shit will turn upside down.

Do you expect addicts to improve their situation when they are treated like dogshit and stigmatized? Kept in the dark and forced to acquire their drug of choice via illegal means? Bringing them out into the light is the only humane way to deal with this. Don't force them to buy 90% gunk 10% active morphine diacetate or whatever their DOC is to maintain their disease.

DEA needs to stop harassing medical professionals about their prescribing patterns. I personally know people in chronic pain that are DRASTICALLY undermedicated and have had to help them supplement their treatment just so they can function because of stupid laws in their area preventing doctors from giving them adequate analgesics. I also know people that because of lack of insurance cannot get things causing them chronic pain surgically remedied -- such as peptic ulcers. They are forced to acquire opioids illicitly to not be balled up in tears in level 6-8 pain day in and day out.

"Controlling" substances causes more misery than it allegedly solves. It ensures that addicts do not have any stability, and ensures that society in general looks down on them as scumbags.