Richard Feldman: The collateral damage of the war on opioids

Keywords Forefront / Opinion

FeldmanWe are in the midst of a raging war against rampant opioid overuse, addiction and overdose deaths. No segment of our society is immune to the human devastation resulting from this epidemic.

But there are other casualties in this war best described as collateral damage. These are the select individuals with chronic, severe and unrelenting pain who find it difficult or impossible to get the opioid medications they legitimately need. Federal regulations and state laws have increasingly regulated and restricted opioid prescribing by physicians and other providers.

Despite fewer prescriptions and less diversion, Hoosier opioid overdose deaths reported in 2017 have continued to increase, due to the fact that heroin and other potent opioids like fentanyl have increased on the streets. In Indiana, legislators have enacted a number of necessary laws to better assure reasonable and responsible opioid prescribing. Understand that the majority of chronic-pain patients on opioids should have never been placed on them chronically. Many others do well on much lower doses.

Legislation passed a number of years ago resulted in the Indiana Medical Licensing Board’s Chronic Pain Prescribing Rule, which applies to non-terminal or non-palliative-care patients’ being prescribed a certain threshold of opioid-milligram amounts or number of pills per day. The rule requires providers to comply with extensive chart documentation, patient drug testing, mandatory discussions, patient assessments, reviews of the patient’s online pharmacy opioid prescription record, and other tasks.

Although the medical community might have concerns about some details in opioid-related legislation, Indiana providers are generally quite supportive of these new statutes and regulations. Unfortunately, the reality is that some physicians, already too busy, don’t want the regulatory hassle and have either curtailed or ended opioid prescribing. Some have reduced the dose of opioids to under the rule’s thresholds to avoid the many requirements.

Providers are under intense scrutiny regarding their prescribing practices, even if well-intended, and fear potential medical licensure actions and criminal narcotics charges. Last year, the Legislature enacted a statute that requires a provider to check an online prescription record of patients before each prescription is written for opioids or benzodiazepines. Failure to do so is a criminal offense.

With these pressures, the opioid-prescribing medical community has contracted, reluctant to prescribe. Patients with legitimate chronic pain are commonly weaned down on dosage, possibly below what is required to control their pain, or told they will no longer receive opioids. If a patient’s physician retires, it might be virtually impossible to find a new willing prescriber. And there is a significant shortage of pain specialists for referral.

I have written a number of columns on the opioid crisis and regularly receive emails from legitimate pain patients seeking advice, no longer able to obtain the necessary opioid medications they once received. These are the forgotten people in government’s efforts to get control over this crisis.

I have brought these concerns for needed balance to the Legislature during committee testimony but received only blank facial expressions. Are these individuals considered necessary collateral damage? Some are dysfunctional, cannot work, are bedridden and even suicidal. Lawmakers should focus, for example, on improved coverage and access to more costly non-addictive medication alternatives, procedures and other non-pharmaceutical treatments and devices.

Former political reporter Jim Shella recently wrote about the tragic loss of a son to an opioid overdose while having other family members who suffer from severe chronic pain necessitating opioid medications. He stated that lawmakers “need a more thoughtful approach.” I agree.•

Click here for more Forefront columns.

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Feldman is a family physician, author, lecturer and former Indiana State Department of Health commissioner for Gov. Frank O’Bannon. Send comments to ibjedit@ibj.com.

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