opinion

Prescription abuse laws can create a no-win situation for doctors

A message to all physicians from Steven J. Stack, MD, chair of the AMA Board of Trustees.

By — Posted Aug. 13, 2012.

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Our nation is in the midst of an enormous crisis of prescription drug misuse and abuse. As physicians, we do what we can for our individual patients, but it is becoming obvious that is not enough.

Data from the Centers for Disease Control and Prevention paint an alarming picture: In 2008, there were 14,800 prescription painkiller deaths — more than 40 per day. For every death, there are an estimated 825 nonmedical users of prescription painkillers.

In 2010, an average of 5,500 people per day reported using prescription painkillers nonmedically for the first time. Nearly 70% of these misusers obtained the drug they used most recently from friends or relatives for free, bought them from friends or relatives, or actually stole them from a friend or relative. Approximately 17% of these misusers obtained the drug directly from a prescriber.

Despite representing only about 4.6% of the planet’s total population, Americans consume more than 97% of all hydrocodone produced in the world. We have such an overabundance of opioids, in fact, that opioid prescribing by physicians increased by a factor of four between 1999 and 2010, and in 2010 we prescribed enough painkillers to medicate every American adult around the clock for an entire month.

It’s ironic, however, that even in the midst of such overuse and misuse of prescription painkillers, a great deal of human pain and suffering remains inadequately treated. According to a 2011 Institute of Medicine report, 100 million Americans suffer from chronic pain. Three in five of those 65 years or older said they experienced pain lasting a year or more; more than 60% of U.S. nursing home residents report pain, and 17% have substantial daily pain.

Lost productivity from common pain conditions among workers costs an estimated $61 billion yearly; the annual economic cost associated with chronic pain likely exceeds $560 billion.

In the 1990s, the American Pain Society launched the “Pain as the 5th Vital Sign” initiative to foster routine pain assessment along with traditional vital signs of pulse, blood pressure, temperature and respiration. It later became part of a Veterans Administration strategy to improve pain management. Around the same time, the Joint Commission declared pain to be “the 5th Vital Sign” and required hospitals seeking Joint Commission accreditation to monitor, record and manage pain symptoms routinely in their patients.

Legislation concerning painkillers is inconsistent at best. Just to put a final exclamation point on the emphasis society has placed on pain management, I offer examples from a few state statutes. A 2000 California law says: “It is the intent of the Legislature that pain be assessed and treated promptly, effectively and for as long as pain persists” (emphasis added). Is it not possible that legislation like this, passed with the best of intentions, might ultimately lead to overuse of opioid medications?

Contrast that with new laws and regulations in my state of Kentucky, plus Ohio and Washington, that swing entirely in the opposite direction. A Kentucky law that went into effect a few weeks ago makes sweeping changes to the standards, requirements and prohibitions related to the use of not only opioids but also all Schedule II and III and 15 Schedule IV medications.

Physicians are now required to register for the state-run prescription drug monitoring program — KASPER, the Kentucky All Schedule Prescription Electronic Reporting program — and must check every patient in the database before prescribing any of the covered medications. The few exceptions are only for periods of less than 72 hours. Failure to follow these requirements can result in suspension or loss of licensure.

If a patient is unable or fails to provide a photo ID, physicians are strongly discouraged from prescribing controlled substances and must meet added documentation standards if they decide that medical necessity requires them to prescribe.

Emergency physicians like me are “strongly discouraged from and shall not routinely: administer IV and/or IM-controlled substances for the relief of acute exacerbations of chronic pain, … prescribe long-acting or controlled-release controlled substances, … administer Demerol (Meperidine) to the patient, … [or] prescribe or dispense more than a three-day supply of controlled substances, with no refills.”

Further, if I prescribe an addicted patient 10 Percocet pills for an acutely fractured arm and that person overdoses a month later, I could be subject to medical board investigation. As a physician, I can’t help but wonder how this will play out in practice. Will physicians be willing to take this risk? And, as a result, what does this mean for the patient?

Additionally, in my emergency department, 56% of patients are either uninsured or on Medicaid, which functionally means they have either impaired access or no access to routine outpatient medical care. The emergency department often is the only place these patients have to turn. And, notwithstanding a widely held falsehood, most emergency department users are there out of legitimate need, not reckless irresponsibility or criminal intent.

I certainly agree that a crisis exists, and Kentucky officials are attempting to address it. The data mandate prompt and decisive action. But the statute and regulations go so far as to nearly criminalize the practice of medicine.

I have spent scores of hours on this topic over the past four or five months. Like the vast majority of physicians, I want to see the crisis of prescription drug misuse eliminated. Our health system, however, is complex, fragmented and inequitable. Moreover, conflicting societal mandates, partially demonstrated above, often put physicians in a no-win situation. While I understand a legislature’s desire to address this crisis, I can’t help but wonder if the policies being considered — or passed in the states — are like overly blunt instruments, not effective in dealing with the underlying complex problems.

I believe it will be largely up to the medical community to make changes.

As physicians, our oath encompasses more than direct care at a patient’s bedside. Our society needs much more from us. Whether on the topic of prescription drug abuse or any of innumerable other challenges, we have the education, the compassion, knowledge and skills to work on behalf of the health and well-being of all of our people.

We have a professional responsibility to find the path to a better place as we struggle to balance compassionate relief of pain against the imperative to control prescription drug misuse.

In part, that is what the AMA is all about. It provides physicians with a voice and a wherewithal to play a role in the political system that more and more governs how we can treat our patients.

For that reason, we are in the process of revising our online pain management CME to provide state-of-the-art educational modules, including specific guidance on responsible opioid prescribing. Additionally, over the next two years, the AMA will host 12 free CME-based webinars on various topics related to the intersection of addiction, pain management and opioid use.

Beyond that, I believe we have an obligation to deal with complex and important matters like this one. It is up to us to rise above the politics of emotion to find a way forward — as we have done so many times before.

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