Lawmakers, seeking to curb prescription-drug overdoses, fast-tracked a bill to make it harder to write prescriptions for large doses of opiate painkillers. Now, as state regulators attempt to write the rules that doctors and other providers must follow, critics predict that making prescribing more difficult won't stem overdoses but will hurt patients with serious chronic...
Earlier this year, statistics showing more middle-aged Washington residents died while taking prescription painkillers than from traffic accidents alarmed lawmakers. So they fast-tracked a law, the first of its kind in the nation, to clamp down on prescribing opiates to chronic-pain patients.
Passing a law, it turns out, was the easy part.
Writing rules to control what happens between doctors and patients, on the other hand, is proving to be a prickly business.
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The rules will require doctors and other prescribers to maintain and update detailed screening, history and treatment-plan records for most pain patients. A prescriber whose patient reaches a certain dosage level must consult a pain specialist.
These rules, unlike similar guidelines adopted three years ago, will carry real weight: A doctor who violates them could find his or her license to practice medicine in jeopardy.
Patient advocates, doctors and others are mobilizing to fight what they see as a micro-meddling, anti-opiate juggernaut aimed at the wrong target.
Drug abusers are the problem, they say — not chronic-pain patients.
Some predict the rules will trigger a return to the days when doctors, wary of patients becoming addicted, withheld pain drugs even from suffering, dying people.
“We’re going to go back to a period where noncancer pain is vastly undertreated. It will happen,” and many more patients will suffer, says Dr. Paul Brown, a rheumatologist and a past president of the Washington Academy of Pain Management, a professional group.
Many chronic-pain patients already have trouble finding doctors, caregivers say, and the threat of discipline will close more doors.
“What happens to these patients? Where do they go?” asks Dionetta Hudzinski, a Yakima nurse consultant for pain and palliative care. “Most of them are saying to me, ‘I’d rather die — give me a gun.’ “
Dr. Charles Chabal, a pain specialist and incoming academy president, says, “I think the law is well-intentioned — addressing a public-health issue that’s been identified and is a problem — but translating that from law to practice in the delivery of health care is much more complicated …
“The devil’s in the details in this law. How do you protect some of these vulnerable people in access to care?”
Need to act
It’s clear why lawmakers felt the need to act.
Workers getting pain medication for a back injury are ending up dead of overdoses a few years later, said Dr. Gary Franklin, medical director for the state’s Department of Labor & Industries, which administers the workers’ compensation insurance program of medical care and compensation for injured workers.
“There are people dying out there, and we’ve got to do something about it,” Franklin said. “There’s a public-health problem, and we need to find a solution to it.”
Dr. Alex Cahana, chief of the University of Washington’s Division of Pain Medicine, said voluntary state guidelines adopted in 2007 haven’t worked. Doctors and other prescribers either aren’t aware of them or ignore them.
Cahana believes it’s time for rules.
“This is not just about addicts, but little old ladies with arthritis starting to die because of this kind of medical practice,” Cahana told The New York Times.
The boards governing doctors, dentists, podiatrists, osteopaths and nurses must adopt rules by June 30. A work group from those boards is attempting to create a draft rule.
The rules won’t apply to patients with cancer, acute injury or surgery, or who are in end-of-life care.
The law’s most controversial requirements include what some see as ominously heavy paperwork for pain-medicine prescribers, as well as the stipulation that when a patient reaches a certain specified dosage — yet to be set by the work group — the doctor must consult a pain specialist.
“Once again, government’s going to tell doctors and patients what they can and can’t do,” complains now-retired Sen. Darlene Fairley, D-Lake Forest Park, one of the few legislators who voted against the bill. “This is just the poster child for how you do it wrong.”
The problem with reducing overdoses is figuring out exactly what — or who — is the problem.
“This topic is ridiculously complicated,” concedes Caleb Banta-Green, of the University of Washington’s Alcohol and Drug Abuse Institute, the acknowledged guru of local opiate statistics.
• In 2008, 10 percent of the state’s 10th-graders reported getting high on prescription opiates in the past month.
• Each year, one in 10 adolescents — and one in five adults — gets at least one opiate prescription.
• Almost 40 percent of heroin users reported previously being hooked on prescription opiates.
This state has the seventh-highest death rate involving prescription opiates, according to federal statistics. Nearly half of those who died were on Medicaid.
Methadone, commonly used for pain, was the drug most often involved in deaths.
And there’s this: Of those who die, 85 percent took multiple drugs — typically an opiate plus Valium, alcohol, a mental-health drug or an illegal drug such as heroin.
A 2005 King County investigation found that roughly half those who died got drugs from a prescriber and half didn’t, Banta-Green said.
So are little old ladies with arthritis really dying because their prescriber was too loose with the OxyContin?
The statistics convinced Fairley, a paraplegic who has more than a nodding acquaintance with pain, that the law misses the target.
“Most of it happens in emergency care — they go from emergency room to emergency room,” she says. “That’s where the misuse is — not with patients who’ve been seeing a doctor for years and years.”
Curbing the problem
To Franklin, of Labor & Industries, the connection is clear: Cut down prescriptions, curb the problem.
“It doesn’t matter whether someone is taking more than they should and died, or took it out of the medicine cabinet and died, or took it on the street and died — it all started with a prescription.”
The dosage level in rules won’t be a “limit” or a “cap,” he says. It’s a “yellow flag” for prescribers to reconsider or ask for help.
But there’s no evidence to show restricting dosages will reduce the number of deaths or overdoses, or make sure the drugs don’t wind up in the wrong hands, counters Elin Björling, state policy specialist for the American Pain Foundation, an advocacy group.
Says Dr. Michael Schiesser, a Bellevue doctor specializing in pain and addiction, “No one has ever showed that calling a specialist at [a certain] dose renders a patient at a safer place.”
In fact, a dosage point could give doctors false comfort at lower levels, he warned.
Others noted that while the law requires some prescribers to consult with pain specialists, such experts are very scarce.
For some, the real worry is that the yellow flag will become a red light for doctors, scaring them from providing adequate pain medication.
The problem, the UW’s Cahana acknowledges, is bigger than simply opiate drugs.
“It’s a combination of a doctor who doesn’t have time to explain, a patient who doesn’t want to hear the answer, and pressure from insurance companies,” he said.
Many doctors say public and private insurers often refuse to pay for pain-relieving alternatives to opiates, including acupuncture, electronic devices that interrupt pain, or non-opiate drugs.
Brown said he’d much prefer to give FDA-approved nonopiate drugs for fibromyalgia pain. “Because insurers turn them down, you end up going to an opioid. That’s pretty routine,” he said.
One recent change many applaud: Swedish Medical Center’s emergency departments in Seattle have become “Oxy-free EDs.”
Emergency doctors there no longer will give out prescriptions for Schedule II drugs, a group including OxyContin and Percocet.
“The medical profession needs to take some responsibility,” said Dr. Russell Carlisle, medical director of Swedish’s Cherry Hill emergency department, the first to make the change. “We’re doing this because it’s the right thing to do, and because the statistics speak for themselves: There’s an epidemic.”
As the work group resumes deliberations, more people are weighing in, many urging members not to lose sight of patients with pain.
Chabal, the pain doctor, says: “Even people who are very conservative in opiate prescribing are saying, ‘Whoa! We need to make sure we’re not going to cause problems we didn’t even think about.’ “
Carol M. Ostrom: 206-464-2249 or firstname.lastname@example.org