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A bill before the New Hampshire legislature would clarify that opioid prescribing guidelines shouldn’t dictate care for chronic pain patients.
There were over 33,000 opioid overdose deaths in 2015, the same year that opioid prescriptions hit 240 million—meaning there was about one prescription for every adult in the country. That amount of prescriptions led many to question whether the opioid crisis could be blamed, at least in part, on doctors who were overprescribing.
In response, the CDC in 2016 published guidelines for opioid prescribing, providing recommendations for a maximum daily amount of opioids a typical patient should be given and alternative therapies for patients with chronic pain. Over a dozen states codified those guidelines into law in an effort to stem the prescription rate—but now chronic pain patients say that getting opioids at the levels they need can be nearly impossible.
In New Hampshire, one state lawmaker wants to change that. “When they put the clamps on, they came to the conclusion that if they could control the overprescribing that would fix the problem,” said state Sen. John Reagan. “Nothing is ever that simple.”
Reagan has introduced a bill that would make it clear that doctors should follow an individualized prescribing pattern for each patient. He said doctors have been refusing to care for chronic pain patients because they fear losing their licenses if they prescribe opioids at a rate that goes beyond the state-mandated guidelines.
The bill calls for providers to “administer care sufficient to treat a patient’s chronic pain based on ongoing, objective evaluations of the patient without fear of reprimand or discipline.” It says prescribing opioids should not be administered based on “predetermined” daily limit guidelines.
The legislation also says that pharmacists “shall not refuse to fill a prescription directly related to the chronic pain diagnosis.” Under the bill, chronic patients would receive documentation from their provider of their condition, which pharmacists would then keep on file. Reagan said he added that provision after hearing from chronic pain patients who were denied their medication because pharmacists thought they were addicts.
State Sen. Tom Sherman, a Democrat and gastroenterologist who helped craft the New Hampshire Board of Medicine’s current opioid prescribing rules, told the Union Leader that the rules were “never to make it impossible for somebody to get the appropriate medicine to treat their chronic pain.” But Sherman acknowledged that he’s heard from doctors “who previously would not have had any problem prescribing opioids [say] now they’re really gun-shy about it.”
The rules dictate that an emergency room, urgent care or walk-in clinic should limit opioid prescriptions to a maximum of seven days worth of drugs, while suggesting that in most cases three days or less would be appropriate. The rules also establish parameters for use of opioids to treat chronic pain, including requiring doctors to consult with a specialist if a certain level of opioid treatment goes longer than 90 days and establish a written plan that includes random drug testing. Opioid prescriptions should be “for the lowest effective dose for a limited duration,” the rules say.
Diane Hoffmann, a professor of health law at the University of Maryland who has written about the collateral consequences pain patients face when states set strict prescribing rules, said that New Hampshire’s experience isn’t uncommon. “Physicians are risk averse,” she said. “Without really understanding what the law says, they might abandon their chronic pain patients by titrating them off opioid or not treating them at all.”
Chronic pain patients often build up a tolerance to opioids, meaning they need higher doses than those who take them for acute pain. But Hoffman said that tolerance is different than addiction. “It’s the same as people who have diabetes and take insulin,” she said. “They take it to function normally, and they’re dependent on it, but they’re not addicted.”
But even as pain patients and doctors around the country have begun to question whether the CDC guidelines were being interpreted too rigidly, some physicians have emphasized how critical they were in stopping an over-prescription epidemic. “The only policies that have reduced opioid mortality are dosing limits,” Dr. Mark Sullivan, a psychiatrist with a pain medicine specialty at University of Washington at Seattle, told Nature.
The CDC in 2019 clarified its position on using the guidelines to treat chronic pain patients. “CDC commends efforts … to improve opioid prescribing and reduce opioid misuse and overdose,” the statement reads. “However, some policies and practices that cite the Guideline are inconsistent with, and go beyond, its recommendations.”
Some of the applications that go beyond the CDC’s recommendations include quickly stopping opioid treatment and using the guidelines for cancer patients. Additionally, the CDC said that “policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.”
The authors of the 2016 guidelines also published an article in the New England Journal of Medicine in 2019 saying that their recommendations were not meant to be used to withhold opioids from people who need them. They wrote that they fear strict policies could result in clinicians who “universally stop prescribing opioids” or drop their chronic pain patients, “which can adversely affect patient safety, could represent patient abandonment, and can result in missed opportunities to provide potentially lifesaving information and treatment.”
At a hearing in January, no one spoke against the New Hampshire bill. Reagan said both the New Hampshire Board of Pharmacy and the New Hampshire Medical Society have seen it and not expressed opposition.
Other states have tried to make alternative pain management therapies more available. Missouri, for example, began offering Medicaid patients the option to try chiropractic care, acupuncture, and physical therapy. But these programs haven’t been widely used—roughly 500 of the state’s 330,000 adult Medicaid users tried the program in its first eight months.
Alternative therapies like the ones Missouri is promoting may work for chronic pain patients, but likely only when they’re used in conjunction with pain medications. The U.S. Department of Health and Human Services released a pain management best practices guide in 2019 that explains “effective pain management, particularly for chronic pain, is best achieved through a patient-centered, multidisciplinary approach” that includes medication, restorative therapy, interventional procedures, and behavioral health approaches.
Hoffman said that there are some cases where chronic pain can be receptive to other treatments. Neuropathic or nerve pain, for example, has been shown to be receptive to low doses of antidepressants. “We need more education about chronic pain treatment. Medical schools devote surprisingly few hours to that,” she said. “There’s a lot of educating we need to do before we just rely on the law to change behavior.”
Emma Coleman is the assistant editor for Route Fifty.
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