The Senate is actually working on a real solution to a real problem where technical experts are being listened to, bi-partisan coalitions have been formed with Senators from opposing parties seeking to find ways to solve a common problem.
Someone please pass me the smelling salts as this is actual good news:
From the Pittsburgh Post Gazette:
The bill was introduced by Sens. Pat Toomey, R-Pa., and Rob Portman, R-Ohio. Sens. As primary co-sponsors, Bob Casey, D-Pa., and Sherrod Brown, D-Ohio, also have been shepherding it through Congress….
As part of an effort to prevent opioid abuse, lawmakers are teeing up legislation that would limit Medicare Part D beneficiaries to a single pharmacy and a single provider for narcotics….
The GAO estimates that 170,000 Medicare enrollees have engaged in doctor shopping, where they go to multiple doctors who then typically unknowingly write duplicative prescriptions that are then filled at multiple pharmacies for the very same painkiller,” Mr. Toomey said. “It’s an easy way for people to find commercial-scale quantities of opioids which they can then sell on the black market.”
Medicaid has a lock-in program which limits individuals who are identified through claims and prescription data as engaging in doctor shopping behavior. The criteria varies by state. In mine, it is seeing enough doctors to organize a pick-up basketball game and filling those prescriptions at several pharmacies that trigger the red flag. The idea behind lock-in is that it forces an individual who has been doctor shopping to choose a single provider who sees on their medical records that this person has a history of opioid seeking behavior. The single pharmacy restriction allows a pharmacist to see the same faces and act as a backstop when usage becomes an outlier which would suggest significant diversion.
As long as there is a reasonable national criteria for what constitutes opioid seeking behavior in the Medicare population, this bill makes a good amount of sense to reduce but not eliminate a pressing national problem.
This is a win. The challenge is getting this bill to President Obama’s desk without it being tied up in half a dozen other pieces of legislation which contain unrelated poison pills.
Jade
This is big brother. They will buy street drugs which is worse. Big government micromanaging the olds.
Cermet
Of course – real people in real pain get screwed; and no, the bill will not protect people who are in real pain. Even now it is very difficult for such people. Figures that these ass wipes can agree on hurting people just because another group abuses a med and need treatment (both types of groups!)
Villago Delenda Est
We really need to rethink the entire issue of opiods in the first place. But that’s not going to happen anytime soon.
This is at least a stab at establishing consistent criteria.
dedc79
@Jade: @Cermet:
I understand this is an emotionally charged issue without simple answers, but dismissing this the way you have is also unfair.
This isn’t just about people who are already in pain and addicted to pain killers; it’s also about preventing future addictions by ensuring that people don’t have access to an unending supply of these drugs.
japa21
As I was reading the first paragraph, I thought you were going to end with a “If only” line. Good to hear that sometimes things can be done in a cooperative manner.
However, I have a feeling if Obama had come in the SOTU and called for this, it might be more problematic. But then, I am somewhat cynical.
Another major contributor to the opioid problem is workers’ compensation. There are some states that are trying to work on this problem because it is real and big. The primary focus for workers’ comp is to get the injured worker back to work as soon as possible, no matter what it takes. Opioids are being prescribed when they really would not normally be to facilitate that process.
Between employers not wanting to see their WC premiums go up, WC insurance companies want to reduce benefit payments, and physicians making a lot of money by being a main referral doctor, the patient gets hooked on opioids but without any follow up treatment recourse. Some states are working to make sure any substance abuse treatment required post WC treatment also be covered under the WC insurance. Needless to say, the three interests mentioned are doing their damnedest to prevent that from happening.
Not sure anything can be done on a federal level.
Gindy51
@Jade: My thoughts exactly. This will only fuel a larger heroin trade, more jail time, bigger police and prison budgets, etc. If these folks could get cannabis based medications that are NOT addictive, it would solve the whole problem, but NOOOOOOO big pharma can’t make any $$ that way.
Paul in KY
@Gindy51: They could if they invested in growing the stuff in Colorado/Washington. Probably don’t like the profit, compared to those little pills.
Anoniminous
So what? If there’s enough money at stake somebodies will set up a lab in Mexico or Latin America and start making the stuff and run it through established distribution channels.
It’s typical Washington: come-up with a non-solution to a serious problem, declare Victory!!!, go home, and ignore it.
Chip Daniels
But certainly, there must be a way to add a provision defunding Planned Parenthood, or repealing Obamacare.
jl
I don’t understand the issue well enough to know whether this will result in better care or nuisance micromanagement and harassment of chronically ill. If docs are prescribing adequate Rx’s then there is no reason for patients to shop multiple docs and pharmacies to cage the drugs, If they are not prescribing properly, then that problem should be addressed through enforcing good standards of care.
Drugs like heroin and etc. should be handled through decriminalization. Half a dozen countries have experimented with decriminalization and medicalization of addiction to opiates, and from what I read, they have sees some success in controlling prevalence of use.
The legislation seems to address two populations: those who are dealers and this is a good way to get a supply and those who are hooked on over prescription for an initial episode of care that requires pain control. What is the relative size of those two groups? I would think the latter is far larger.
A cynical question for anyone who knows. For the cases I keep hearing about where 2 pills will do, but the doc prescribes 10 times that amount, how does that happen? Cynically, what is role of Big Pharma and PBM ‘marketing incentives’ (kickbacks) and package deal pricing for portfolios of drugs that Pharm company or PBM, or both, offer providers?
And to be super cynical, there is an iatrogenic drug marketing angle here. I’ve noticed very recently a deluge of commercials for drugs that relieve side effects of opiate use, particularly constipation and prevention of mega-colon.
? Martin
Nice to see that Congress will work on a problem once enough white Republicans (I’m being redundant, I know) are affected.
Kay
@Gindy51:
It gets complicated though, because Big Pharma is lobbying heavily to keep the money train on track.
It’s really shocking how aggressively this was sold, and where it was targeted. We had a presentation from the Ohio AG and when they start to color in the map you see this was a targeted campaign and it was directed to low income people. The rate these drugs were prescribed went up 10X over 5 years. It is hard for me to believe that people had 10 times the pain they had 5 years prior. The marketing itself creates a prison population because they will beg, borrow or steal the prescription drugs and when they can’t get those they go to heroin.
Bob Latta, US House, was at the same presentation I was at. The AG specifically called out Purdue Pharma for pushing the drugs in Ohio, and my AG is a wingnut.
jl
Also, I need to check, but I think CA already has a system to spot multiple scrips for high risk drugs when people shop multiple pharmacies. Supposed to stop a fill until pharmacist can contact the doc.
If that systems works like I think it does, I wonder how well that is working.
Matt McIrvin
I immediately started wondering about the intersection of these lock-in restrictions, and pharmacists’ conscience clauses that allow a particular pharmacy to block people from getting contraception.
But I don’t suppose many Medicare recipients are looking for emergency contraception (and does it only apply to opioid purchases anyway?)
Origuy
My housemate, whom I’ve mentioned before, has Ehlers-Danlos Syndrome and arachnoiditis. She is in constant pain and will be for the rest of her life. Ok, she’s addicted, but she’s addicted to not dying in agony. She has been on morphine, methodone, and is now on fentanyl patches. She doesn’t “doctor shop”, she has multiple doctors to treat her many genuine afflictions. Right now she gets all of her medications from Walgreens, usually a single one affiliated with Stanford Medical Center. However, if they are out of stock, she can go to a different location, which still has access to her records. She’s on MediCal, California’s MediCaid. Does “single pharmacy” mean single location or can she still go (actually send me) to another branch? If not, and the one location she is limited to won’t get her meds in stock for a few days, she will have to go to the ER to tide her over. That won’t save any money.
Origuy
And of course my post is in moderation, because I mentioned the place where you can obtain medicine.
pseudonymous in nc
@Gindy51:
Or maybe not, y’know? Cannabis isn’t the answer to every question.
This is a clusterfuck of problems: overprescription to those who don’t need opioids, underprescription (and dismissive treatment) for those who need pain treatment, and a set of perverse incentives to turn granny and grandpa into low-level pill dealers.
Kay
@Gindy51:
The prescription drugs themselves are creating a prison population. They will beg borrow or steal to get them once they’re addicted. Once they can’t get them they go to heroin.
Big Pharma is actually lobbying heavily to keep the money train going:
We had a presentation on it from the Ohio AG. They targeted poor people. When they start to color in the Ohio map with the rate of prescribing these drugs you see the pattern appear. The AG specifically called out Purdue Pharma. Use went up 10X over 10 years in Ohio. Are people really in pain at 10X the rate they were in 2006?
CONGRATULATIONS!
Lost one friend to Oxy addiction. Lost several friends to cancer.
I’m willing to keep losing friends, if that’s what it takes, to insure that people in pain get enough medicine. Because I’m going to be in that place too one day. And there is no hell that you can imagine that is like the pain of someone with cancer.
While this bill addresses some supply issues, it does not cover what I consider the fundamental issue: people in pain are not being adequately treated – not even close – for their pain. And doctors are terrified to prescribe appropriate amounts of painkillers for legitimate fears that the DEA may just waltz in and take their license.
The problem is not the pills. Or the docs, or the pharmacies, or even big pharma. It’s the people taking them for kicks. Deal with the problem.
pseudonymous in nc
@jl:
I think there’s more of a cultural expectation in the US that a) doctors will prescribe strong painkillers or benzos; b) that they’ll prescribe a little extra, implicitly for hoarding ‘just in case you need them’; c) they expect patients to demand them. I know that my fellow non-USians here are always surprised to get loaded up with opioids for things like dental treatment.
elmo
@CONGRATULATIONS!: Goddammit, thank you for that. I am so fucking tired of people in pain being stigmatized. People are seeking drugs! OMG we must put a stop to it!
Okay. Then they’ll do what they have always done, which is self-medicate with whatever comes to hand. Beer’s good. Vodka’s better. And then we can all preen in glorious self-satisfied moral superiority as we look down on the weak and lazy drunks who can’t hold a job and die in squalor.
Fuck. I swear to FSM, and I mean this with all my heart: if Donald Trump adopts a platform of muzzling the fucking DEA when it comes to pain management, allowing physicians to actually prescribe drugs that relieve pain in the quantities needed to relieve pain, and removing the awful stigma attached to people who just want to stop hurting for the love of God, I will not only vote for him – I will volunteer and walk precincts and donate to his campaign.
elmo
@jl:
Have you lived in this country very long? Nuisance micromanagement and harassment of the chronically ill are two of our national sports.
Origuy
Reposting my earlier rant which is stuck in moderation.
My housemate, whom I’ve mentioned before, has Ehlers-Danlos Syndrome and arachnoiditis. She is in constant pain and will be for the rest of her life. Ok, she’s addicted, but she’s addicted to not dying in agony. She has been on mor**hine, meth*done, and is now on fent*nyl patches. She doesn’t “doctor shop”, she has multiple doctors to treat her many genuine afflictions. Right now she gets all of her medications from Walgreens, usually a single one affiliated with Stanford Medical Center. However, if they are out of stock, she can go to a different location, which still has access to her records. She’s on MediCal, California’s MediCaid. Does “single ph*rm*cy” mean single location or can she still go (actually send me) to another branch? If not, and the one location she is limited to won’t get her meds in stock for a few days, she will have to go to the ER to tide her over. That won’t save any money.
ETA: MediCal won’t authorize payment until the patient is almost out. There’s no way to prepare for a long weekend or shortage at the medication-seller-place.
Frank Wilhoit
@elmo: If Donald Trump adopts a platform of {whatever whatever whatever anything at all}, only a fool would believe him.
Cermet
@dedc79: Prevent future addiction!? Really? All you achieve with such draconian measures is that honest people in pain are screwed. Addicts will just pay more and get it – treatment, not jail is needed for addicts; and the treatment needs to be with real opium based drugs – maybe then that will do the trick compared to the joke of a treatment system we now have and even then, expect many failures by the addict – compassion is needed not stupidity of “cut off the drugs and of course everything will work out fine BS. Or unfair to the police who enforce and, in turn, are corrupted by these laws; or maybe the doctors caught in the complex legal web so they error on the side of pain for all? Get real. This has but one purpose – a war on sick people: both addicts and the vast number of cancer/old people in constant pain who will quickly have their required need form pain relief curtailed.
glory b
Off topic, but:
The Library of Congress has now put the Rosa Parks archive online. Postcard from MLK, pictures and a recipe for “featherlite pancakes.” It covers 140 years of her family history.
7,500 manuscript items and 2,500 photos!
elmo
@Origuy: That brings me to another rant. The concept of “doctor shopping.” If I go to a plumber and I don’t like his attitude, or his estimate, or the color of his shoes, I am perfectly within my rights to go to another plumber. If I go to an electrician and he tells me he doesn’t believe in interior wall wiring, but will only string wires on the outsides of walls to reduce fire danger, nobody would look at me sideways for going to another electrician.
But if my wife, who has multiple issues including both fibromyalgia and cervical dystonia causing chronic and intractable pain, happens to be referred to a doctor who “doesn’t believe” in opioids for pain and “doesn’t believe” in fibro (and yes, this has happened), she is in danger of being accused of “doctor shopping” when she decides to seek actual treatment that will help.
We’re Americans. We shop, that’s what we do. If I don’t like my fucking doctor, what fucking right has the fucking DEA to tell me I have to stick with the sorry son of a bitch because otherwise I’d be “doctor shopping?”
Good Christ almighty on a twelve foot purple pogo stick, but nothing gets me angrier than this entire topic. Let my wife shop for a doctor just as we would shop for any other professional, and leave us the fuck alone.
elmo
@Cermet: Sick people aren’t real Americans. Didn’t you know that?
pseudonymous in nc
@elmo:
Oh, come on, that’s not what’s being discussed here. It’s the people who take advantage of the fact that each provider is a special snowflake and there’s no information-sharing between them, and get multiple prescriptions that they file in multiple places. It’s Rush fucking Limbaugh.
It doesn’t help your argument to act like this doesn’t happen, or that the buses going down to the bullshit “pain clinics” in Florida either don’t exist or are simply serving people who need treatment.
Mary G
This scares the shit out of me. In my current rheumatoid arthritis flare, I’ve been taking pain meds left over from my ankle surgery in October 2014, and after those were done, some oxy# prescribed in 2013 which has expired but still works. It’s already hard to get here in CA so I hoard it. This bill makes me feel like the baby who’s getting thrown out with the bathwater.
NotMax
Every time I run across the term opioids, cannot help but picture a made-for-TV movie about an army of freckle-faced redheaded kids (with obligatory spooky eyes and sinister smiles exposing sharp incisors) terrorizing a bucolic hamlet.
Cermet
@elmo: I know far better than most since I lost a bother to addiction, both parents far before their time due to drugs (mostly but not excursively to alcohol) and even destroyed my marriage. None of these were real amerikans …of course, neither am I since I do not believe these or anyone is a criminal because they are addicted or are in pain (physical or mental.)
Mary G
@elmo: Sorry, I meant to thank you for your righteous rants, but I forgot and it won’t let me edit. Also, too Cermet.
elmo
@pseudonymous in nc:
It’s like voter fraud. Sure it happens. And every measure you take to try to stop it is going to have the much larger effect of disenfranchising thousands of other people.
When the DEA tells doctors that their licenses are on the line if they overprescribe opioids, and nobody anywhere ever tells them that their licenses are at risk if they underprescribe or ignore pain entirely, guess what happens? You are setting up a set of incentives all weighted in one direction. By doing that, you will catch one or two pill mills, sure. And you will also consign thousands of helpless, voiceless, disabled people to intractable suffering. By the very nature of the disability or disease, these people aren’t activists. They don’t have SuperPacs. They don’t demonstrate, or protest. They can’t. They are struggling every day just to get dressed and function. And what we are saying to them is, “Better you continue to suffer than we should allow your neighbor to get high.”
And that’s evil.
Karen
@Mary G: And now they’re doing it with Tramadol and Tramadol ER which isn’t even a NARCOTIC. I have RA too and without that Tramadol and Hydrocodone I wouldn’t be able to talk. Eventually addicts are going to cause the government outlaw these meds that keep us from crippling pain.
Cermet
@pseudonymous in nc: And who are you to control people you have no fucking idea if they are really in pain or even if they are addicts? If the addict gets his/her high unless they are stealing/robbing for it they hurt you? BS. This is no different than a woman’s right to chose – her reasons are hers and her’s alone. If someone is shopping for doctors because they are an addict – fine. Offer treatment but to prevent honest people from shopping for doctors because they are in real pain is monstrous. No doctor will treat real pain with a running prescription exactly because we already have draconian laws that more often than not, prevent this already – the last thing we need are more laws making certain real pain is forced on one and all who are sick/injured..
elmo
@Cermet: Sometimes the most infuriating irony is that my wife’s most effective prescriptions have to be renewed in person every 30 days. In person, not over the telephone.
Dude, if she were well enough to drive to the doctor’s office once a month she wouldn’t need the damn prescription. Thank FSM i’m in a position that I can take a day off work whenever she needs to go…
Cermet
@Mary G: Thank you – I do not like illegal drugs BUT I know that both addicts and sick people need those drugs. Give them what they need – both groups need treatment first and foremost and that means access to pain meds – period. Treatment for addiction is something that can be included as needed but never with jail – that ONLY feeds our sick police state.
Karen
@Mary G:
I have RA too and it pisses me off how hard it’s getting to get even Tramadol, which isn’t even a narcotic but it is a controlled substance. Eventually we won’t be able to get these painkillers at all and be left in crippling pain because of it.
boatboy_srq
@Cermet: Well, that IS how we got the show-ID-for-your-decongestants policies…
Cermet
@elmo: The Catch 22 is ironic but I am not surprised at all – but if more laws are made, the next requirement will be to prove, through a one year wait, that you need a pain med and then you be prescribed a 30 day supply. Then wait another year for a refill… maybe. These are the same sick fucks that put people in jail for addiction – an illness! Only when these ass’s or their children end up in jail, or addicted do they understand the issues (unless one is that ass wipe shit eating monster rush.)
Roger Moore
@pseudonymous in nc:
Heretic!
Cermet
@boatboy_srq: And all that did was make it difficult for us but in no way or manner put a dent in that problem drug. Does add to the police state mentality that now controls all our lives even more so than the draconian 9-11 laws …
OzarkHillbilly
Obviously, Obama has had nothing to do with this bill.
boatboy_srq
@elmo: Exactly. I have a friend with TBI (multiple head traumas, including two nasty car crashes) in a similar situation. She was a national rep for someplace-I-can’t-recall, and can’t do the job anymore because travel is such a PITA for her: either she stocks up ahead of a trip, or she has to visit a specialist everywhere she goes (who naturally questions her already diagnosed and copiously documented condition). I’m sure she’s been at risk of “doctor-shopping” cutoff for some time already. Making this process more difficult doesn’t seem helpful.
boatboy_srq
@Cermet: There is indeed something wrong with a society when all its members are presumed to be criminals.
Mary Jo
What is “draconian” about limiting a person to one pharmacy? I don’t think the occasional issue a pharmacy being out of stock of a particular drug is one that can’t be overcome.
Doctor/pharmacy shopping is very well known addict behavior.
People who are physically ill with a pain-producing problem may typically have several doctors, but they’re not getting opioids from each of them and then taking each opioid prescription to a different pharmacy. That’s not typical of physically ill people, but it is very typical of opioid-seeing addicts.
Anywho, the legislation I’d like to see is to support addiction treatment-on-demand, including medication-assisted treatment.
Also, I really do empathize with the difficulties getting medications for travel or during travel and other problems people have encountered. This is definitely a problem.
Fair Economist
@Gindy51:
In the long term, this *does* largely fix the problem. The ultimate problem is that the legal drug companies push opiates on to patients because they make so much money from them. But they don’t make their money from the 30 pills somebody goes home with (more on that later), they make it on the thousands of pills the patient they successfully hook buy later. Doctors are mostly aware of this and putting the brakes on it but this doctor-spamming has emerged as a new way to get pills now that it’s getting harder to get them.
If we can cut the profits of the legal drug manufacturer, we’ll eliminate their incentive to hook people and drastically cut down on the new addicts. It doesn’t solve the problem of the old addicts, but at least we won’t be digging deeper into the hole.
IMO the biggest thing would be to eliminate people going home after surgery with large prescriptions for opiates. At-home opiates should be limited to a few days at most unless the doctor can reasonably certify the patient as one for whom addiction is an acceptable outcome (e.g. terminally ill and perhaps intractable pain). A month of opiates will addict almost everybody; most will be able to break the addiction at that point but you will be significantly habituated to the drug. Even if the patient has the sense not to take the pills, they generally hang around in the medicine cabinet to addict some teenager.
Elizabelle
Maybe you guys should contact Sherrod Brown’s office, or send him a copy of the thread? I wonder if he and the other Senators and their staffs have heard your concerns from other constituents, or could inform you of any flexibility in the legislation or as envisioned in practice?
I am sorry to hear of those who are in chronic pain. Terrible burden, and I believe you all about your concerns.
Still, I can see where Congress would like to act to prevent more opioid addiction, and particularly senators from that region.
Mnemosyne
@Cermet:
So prescription drug theft by family members is almost unheard of? I didn’t realize it was so unusual when it turned out that my asshole sister in law was “borrowing” opioids from her dying father. Because, you know, she needed them more, and she’s never going to go into treatment, because she’s not a real addict since she takes pills instead of shooting up.
But, hey, she’s made an adult decision to be an addict and the effects of that on her 10-year-old daughter don’t matter, because Mommy’s problems should always outweigh the needs of her child.
Mnemosyne
@elmo:
Does your insurance allow the option of using a mail order pharmacy? If so, the doctor may be able to write a 90-day prescription that you can send to them and then she only has to see a doctor every 90 days. That’s what they do with my Concerta, which is also a Schedule II.
Mnemosyne
Argh! Please free me from moderation so Elmo can see a possible way for her wife to only have to see a doctor every 90 days using a mail order p-word.
OzarkHillbilly
A Louisiana Republican tells the unvarnished truth: JP Sheriff Normand calls Jindal a ‘cult leader’ during speech
Too fvcking good.
Bob In Portland
Perhaps they should ban heroin from Afghanistan too. That’ll work.
Nate Dawg
Love that this community sticks up for the disabled and chronically in pain people. M
I see this crap on FB all the time, and the reactionaries that foam at the mouth to TAKE AWAY THEIR LICENSE AND THROW THEM JN JAIL, and rarely does anyone ever point out the suffering that will cause.
There was a law to prohibit pediatric Oxy and everyone on FB was acting like doctors were trying to turn children into pill-popping addicts instead of he obvious–some kids are in awful awful pain.
Carol
@ Richard Mayhew
Are you saying that seniors are the main distributors of opoids?
NCSteve
I don’t care how good it is as policy. It is simply improper for the Senate to be legislating, passing laws that affect the entire nation, with only 325 days left in the terms of a third of them. They should cease work and let the American people decide whether they want them to pass laws of this kind.
Carol
@ cermet #2 My thoughts exactly.
Paul in KY
@NCSteve: Well played!
dedc79
@Cermet:
I am all for a better treatment system modeled after ones that are shown to work. Unless this problem is tackled from all angles it won’t help anyone. So, yes, cutting off supply without doing anything else, is problematic.
At the same time, a system whereby people are able to fill the same prescription at multiple locations is also problematic, for many reasons.
Mnemosyne
Also, for people dealing with fibromyalgia and other arthritis-like conditions, talk to your doctor about possible dietary changes. It doesn’t help everyone, but a lot of people have found relief by eliminating gluten, nightshades (tomatoes, eggplant, etc), sugar, and/or nitrates.
japa21
@OzarkHillbilly:
And it wasn’t just Jindal that he was going after
trollhattan
@jl:
“Mega-colon”–is that a thing?
I’m so working it into a conversation by day’s end.
elmo
@Mnemosyne: Mnem, thank you very much – I know whereof you speak, but we have been advised that it won’t work. Most of her scripts can be filled that way, but not this one. Says the prescribing doc.
trollhattan
@OzarkHillbilly:
Whoa, somebody fetch me a fan and some sweet tea, I need to take a moment.
Roger Moore
@CONGRATULATIONS!:
I’m not sure that you’re correct. My understanding is that the biggest problem is not with recreation users but with people who have been taking them for chronic pain. Opiods are great for short-term pain management for things like surgery, chemo, or terminal illness, but there’s a serious problem with users developing a tolerance. When people have been using them for years or even a decade or two, they can eventually develop a strong enough tolerance that they don’t get much relief even from the largest safe dose. At that point, people try to get even stronger doses but can’t get their doctors to give them more, so they wind up going to multiple doctors or buying on the black market. The real solution is doing a better job of distinguishing chronic pain from acute pain and getting chronic pain sufferers treatment options that are designed to deal with their problem.
jl
@trollhattan:
It’s a serious side effect of chronic opiate use.
Megacolon
https://en.wikipedia.org/wiki/Megacolon
Mnemosyne
@elmo:
Feh. I was hoping it would be something as simple as the prescribing doc not realizing you had the mail order option available.
Betty
How sad that the area where Congressman work in a bipartisan manner happens to penalize people in pain. More “War on Drugs”- which has not worked.
jl
@Roger Moore:
For people with chronic pain, giving them relatively cheap pills might just be cheaper in the short run, and drug companies, PBMs and docs figure why not save costs in the short run and worry about problems later (or take the good bet that someone else will have to deal with problems later).
Controlled and local administration of drugs to strategically intercept pain signals, and lengthen effect of opiate, takes equipment, training, closer medical supervision (more doc and nurse time). Why pay for a pump or place a local administration device, or invest in biolectrical therapy. Why pay for combination therapy of opiates and anti-anxiety drugs, for example. Incomplete or inadequate treatment can worsen pain over time and turn what should be acute pain that goes away into chronic pain.
Maybe just cheaper in the short run to prescribe a strong single drug that will take care of, or mask, the problem now and hope someone else picks up the costs later if any problems develop? The US health care system is good at that approach.
Mnemosyne
@Roger Moore:
Also, this. There need to be better options for people with chronic pain. Right now, it mostly seems to be a choice between opioids or being in constant pain without a lot of options in between. Long-term opioid use is not risk-free and can cause health problems all on its own, but right now people have to do it because they aren’t offered any other realistic options.
Overall, our system sucks at any kind of care for chronic conditions, so this is really just a symptom of that systemic problem.
boatboy_srq
@Mnemosyne: I don’t think anyone here is arguing that prescription abuse is not a real problem. The issue here, though, is tricky: how do you continue to effectively treat real patients with real ailments while reducing abuse. The consequences for patients with legitimate issues could be severe: stopping abusers while minimally affecting sufferers will take careful execution.
Is there anyone here (hint hint, Mr. Mayhew) who can speak reasonably to prescription abuse as an issue? Obviously it’s a real thing, but us laypeople hear so much about it that it begins to sound like the libprog version of the Great Crime Wave that is sweeping the US (of which Fauxnews finds so many instances and for which the Reichwing blames the Kenyan IslamoFascoSoshulist).
gvg
I know chronic pain is a problem but I don’t think this law is about that. People getting multiple doctors to give the same prescription multiple times is the problem meant by Doctor shopping. Communication so that all the doctors and all the pharmacies know about each other is the aim. Its actually dangerous to people to overdose if they are taking all the drugs themselves but the presumption here is they are selling which, is not acceptable.
There are always multiple good groups whose competing interest’s must be weighed. People in pain need fair treatment. People who don’t want other people to die of addiction do too. Some regs aimed one way have harmed the other way. We need better regs sure. As described this does not sound that bad to me. Maybe it could be better. Exchanging the records better seems key and also seems to have been hard so far. Very non standardized Doctor and Hospital records have been hard to deal with is my understanding.
jl
@gvg: I know there are research programs on developing tools for trying to discriminate. Among clinicians, at least, the cost of a false signal of abusive behavior or drug seeking is considered to be very high, and the machine learning and data mining programs that I have heard about are not considered satisfactory.
Thinking more about what I saw in the link, the particular approach of this legislation can be problematic if I understand it correctly. It seems to mean that one patient is allowed to use one pharmacy (for every Rx or just the pain meds?). If for every Rx, that would limit a lot of patient (and pharmacy ‘price clinics’) to find affordable ways to obtain drugs (mail order for this, chain pharmacy for that, local independent for the other). And pharmacy chain / medical group / PBM contracting games mean that a patient who uses a chain pharmacy may have to switch because somebody drops a contract (and BTW, this is the kind of socially wasteful BS that the PPACA still allows to run rampant, and causes serious problems with expenditure and quality of care).
jl
@boatboy_srq: @jl: My original replly in moderation because of naughty words. Let’s see if I can find them all:
I know there are research programs on developing tools for trying to discriminate. Among clinicians, at least, the cost of a false signal of abusive behavior or drug seeking is considered to be very high, and the machine learning and data mining programs that I have heard about are not considered satisfactory, so far.
Thinking more about what I saw in the link, the particular approach of this legislation can be problematic if I understand it correctly. It seems to mean that one patient is allowed to use one dr * g store (for every R eks or just the pain meds?). If for every R eks, that would limit a lot of patient (and far m a s i s t ‘price clinics’) approaches to find affordable ways to obtain drugs (mail order for this, chain farm a seeeee for that, local independent for the other). And FARM chain / medical group / PBM contracting games mean that a patient who uses a chain farm a see may have to switch because somebody drops a contract (and BTW, this is the kind of socially wasteful BS that the PPACA still allows to run rampant, and causes serious problems with expenditure and quality of care).
trollhattan
@gvg:
All valid and important points. In addition to doctor shopping for fun and profit, there are hypochondriacs (I know whereon I speak here) who pore through medical encyclopedias and the PDR to 1. self-diagnose what’s Really Going On and 2. find the drug(s) to treat it. Then it’s off to the doctor to get him/her to agree and treat and wen denied, go find a doctor who will.
This is common and a big problem, made worse by the drug companies advertising their wares on the teevee machine.
boatboy_srq
@gvg: The problem being addressed is definitely doctor shopping (either for prescription abuse by the patients themselves or for illicit resale), and keeping physicians and pharmacists informed is a very good step. However, it’s not clear how
…will achieve that without both adding unacceptable hurdles for legitimate patients and mandating significant additional public sector machinery.
JaneE
Never are the needs of anyone in chronic pain considered, much less the needs of people with chronic pain for whom opiates are the only medication that won’t drive them to kidney or liver failure. There has to be some way to address abuse that doesn’t make life more miserable for the majority of opiate users, but it will never be found unless the people making the decisions realize that pain is a problem too.
My health provider already does what this law would do – gives me one doctor, and one pharmacy (with multiple locations). What they cannot do is prescribe a 90 day supply of opiate medication, or even enough to cover my not to exceed dosage for a month, because law. Not only do I pay three co-pays instead of the one my contract specifies and make three trips to the pharmacy instead of one like all my other medications, but what I get won’t be enough to get me through an entire month unless I have a long string of really good days or just avoid things like lifting or bending or steps.
Most people in pain are not physically dependent on opiates, and those that are still need some relief from their pain. Addicts are people who don’t need the pain relief, but they are physically dependent on the drug and need to have their addiction treated. At best, this law may identify some of these people, but will they get the help they need? About a year ago the pharmacy I normally go to ran out of my opiate medication – as a direct result of the change in regulations that prevented the central pharmacy from filling refills. How are the patients who are locked into one pharmacy going to deal with things like that – besides going postal from pain?
Mnemosyne
@boatboy_srq:
There is a respected study from late last year showing that life expectancy for lower-class white Americans has gone down, primarily due to deliberate suicide and drug and alcohol-related deaths (overdoses, liver disease, etc). That’s one of the reasons this issue is getting so much attention. It’s a major public health problem but we’re Americans — we don’t DO public health.
Origuy
@Mnemosyne: How many of those suicides and ODs were by people in chronic pain?
Mnemosyne
@Origuy:
No one seems to know, but if a significant portion of the white population (and only the white population) is in severe enough chronic pain that they’re killing themselves in large enough numbers to change the overall life expectancy for the entire demographic, that’s a major public health crisis in and of itself.
Bill
@Gindy51:
I see this argument a lot, and I don’t get it. First, why would cannabis be a substitute for opioids? My understanding is that they do very different things.
Second, why can’t “big pharma” make money off of cannabis? Seem to me Bristol-Myers’ “Jointophan” will sell just as well as any other. Hell if they come up with just the right seeds it may even be patentable.
Iowa Old Lady
A friend of mine is in the process of dying from an unidentified immune disease. She’s a pharmacist which adds a twist to this. She recently went into hospice and was deeply relieved because the pain management philosophy shifted from “reducing pain until you can endure it” to “no pain or anxiety.” She’s addicted and knows it, but so what?
Obviously there are multiple constituencies to be served here. I hope people like my friend aren’t going to be sacrificed.
jl
@Mnemosyne: I don’t have time to get links. But those are overall results for both men and women, and OK for comparing US to other countries that have similar ‘baby boom’ effects. So, the conclusion that the US looks horrible compared to other European countries is valid and reliable.
But for comparing trends over time in US, the mortality rate is rising for women, but not for men. And for women, this just shows a worsening of a truly horrible and disgraceful 30 year trend in stagnant mortality rates for women in the US. In terms of public and population health, the US has been a killing ground for women in US over last 30 years or so.
OK, I remembered a good link:
Death rates have been increasing for middle-aged white women, decreasing for men
http://andrewgelman.com/2015/11/10/death-rates-have-been-increasing-for-middle-aged-white-women-decreasing-for-men/
WaterGirl
@Iowa Old Lady: I’m so very sorry about your friend.
More generally, why is it acceptable to just reduce pain to the point that you can endure it? That’s fucked up.
jl
@Mnemosyne:
And here is a recent link I missed with evidence that the problem is concentrated in the South
Middle-aged white death trends update: It’s all about women in the south
http://andrewgelman.com/2016/01/19/death-trends-update-its-all-about-women-in-the-south/
And, this is averaged over income. If you break out by income classes and region, the problem is being a women who is poor OR in the South, IIRC. I’ll have to try to remember what research showed that.
Geeno
@Mnemosyne: Didn’t our own blogmaster have such an experience when he switched his eating habits in deference to Shawn’s dietary requirements. He reported that a hundred little aches and pains just went away.
FlipYrWhig
@Mnemosyne: IIRC I just saw somewhere recently (LGM maybe?) that the stat in question, once properly disaggregated, showed that the phenomenon was affecting women more than men.
JaneE
@Roger Moore: It’s not that simple. Even though opiates are the least effective of the options for arthritis, they are my only option. 16 years ago my nephrologist said NSAIDS would put me on dialysis in 6 months. I am still not on dialysis, and want to put it off as long as possible. The pain gets worse and the tolerance goes up, but not enough to make dialysis look good yet.
elmo
@gvg:
It doesn’t have to be “about” that to affect that – hence the entire concept of “unintended consequences.” And when you set up an edifice of laws and regulations, you don’t just affect the people it’s “about.”
It happens a lot – there is a high-profile problem about which people cry, Something must be done! So something is done, and it affects the high-profile problem somewhat, while making life miserable for a very large population of largely unnoticed people. Then the problem we have created for those people is ignored, or minimized, or counted as their own damn fault.
The chronically ill are invisible in this country. That’s why the Republicans can get away with saying “Everybody gets care, just go to the emergency room!” Nobody thinks about the people with lymphoma, or diabetes, or neuropathy, or any of the other thousand horrible and disabling conditions that flesh is heir to. So it is here. People in chronic pain are handwaved away. “Oh, certainly they should get care, and we’ll somehow see to it that this entire edifice of regulations and negative incentives and reimbursement structures leaves room for them. Somehow.” But it doesn’t happen. In our Puritanical zeal to stamp out “addiction,” and prevent people from having “more drugs than they should,” (how many are those, pray?), and limit our compassion only to the truly deserving (meaning only the healthy), we turn our faces away from those most in need.
WereBear
Cannabis has analgesic as well as anti-nausea effects. A famous little person actor from Magnum, P.I. found it was the only way to help his chronic joint pain, for instance.
Iowa Old Lady
@WaterGirl: Thank you. She’s very dear to me.
As a health professional, she suffered the same shock I’ve seen other suffer when they become patients instead of health care providers. Suddenly, they’re assumed to know nothing, not even the state of their own bodies.
Origuy
Cannabis helps my housemate sleep through the night. She doesn’t like the sensation of feeling high all the time, so she doesn’t take it during the day. It’s not a substitute for opiods, but it complements them.
Diet won’t cure the scarring in the arachnoid membrane of her spinal cord or the defective collagen caused by EDS, a genetic disorder.
Mnemosyne
@Iowa Old Lady:
Hospice is different, because the assumption is that you no longer have to function in ordinary life with a job, housework, driving, etc.
Iowa Old Lady
@Mnemosyne: She hasn’t been able to do any of those things for at least 6 months, but she could afford good home care. Her pain has been through all this.
The fact that she has something that can’t be readily labeled drive the providers crazy because they have to categorize stuff for insurance.
Germy
@elmo: well said.
amygdala
@boatboy_srq:
After many years of lurking, at last a topic on which I might be able to contribute something useful.
Disclosures: I spent the last couple of decades of my career as a neurologist working in a public safety net hospital. In addition to seeing many patients addicted to just about every and [edit to add] any drug you could imagine, I also took care of patients with neuropathic pain. I have participated in research, funded primarily by state-level public funds, on addiction and on medical cannabis. Since graduating medical school, I have worked for and in public and private universities and a major federal health agency. I have not worked for the pharmaceutical or biotech industry. I retired last year.
The New England Journal of Medicine recently published this history of narcotic addiction in the US over the past century or so, including the status of the current epidemic. I’m no medical historian, but it reads to me as pretty accurate. We’re in a bad way in the US with regard to opioid use, both compared to our peer nations, and our own history. The reasons for this are multifactorial. It’s not just Big Pharma. Pain as the 5th vital sign, which had roots in the VA, played a role. Prescription opioid use increased, and has been followed by a spike in heroin use. The consequences have been awful.
Frontline just looked into this, and I would recommend this for anyone interested in the topic. Again, in the interest of full disclosure, my experiences on the front lines have made me a true believer in treatment on demand and harm reduction approaches for addiction. The criminal justice system can be a bit of stick to go along with the carrots available the health care system, and is an intervention point at which people realize, “Okay, I need help… help me, please?” Anecdatally (intentional misspelling), I have found that a lot of cops feel the same way. It’s one of those areas in which the disparate political leanings of law enforcement and front-line health care workers find common ground.
The issue is how to address this without making things worse for people with chronic pain. The incentives are all over the place, which is in part why physician behavior is as well. I don’t think I’m alone among physicians in believing, based on evidence, that cannabis has a role. However, the idea that it will solve all or even most problems with chronic pain management does not strike me as supported by available evidence. Also, doctor-shopping happens. I don’t know if the scope of it has been quantified, but I have gotten enough phone calls from sharp-eyed pharmacists notifying me of altered prescriptions and other efforts to game the system not to know that it happens.
That brings me to my last point, which is that high-level prescribing is not just an issue of patients being allowed to do what they want to themselves. A consequence of patients getting scrips for hundreds of strong opioid pills is so-called diversion: selling them to others, and not only to people with untreated pain. It’s important not to equate physical dependence with addiction. Cancer patients, for example, on opioids for, say, bony metastases, may withdraw if they run out of meds. That does not mean they’re addicted. Experts argue about what addiction actually is but craving with subsequent compulsive use seems to be an important component.
I am at best ambivalent about Congress being involved in this, because there is real risk of making life worse for people living with chronic pain, in part because onerous rules tends to put off providers further, while doing little to slow the epidemic of opioid addiction. That they’re working on it I do take as a good sign; it means they’re aware that there is a big problem. I wonder if Richard might be able to weigh in on whether there may be ways of testing better systems, in the interest of better quality, less expensive care, within the ACA.
I’m about to go to the airport and will be offline for a bit, but thought I’d add a few points for consideration. I’ll check back in later tonight and keep an eye on subsequent threads, if anyone has questions.
pseudonymous in nc
@Cermet:
Really, that’s your preferred analogy? See if you can get a refund on that one.
When you have a healthcare system that subsidises one group’s prescriptions, with relatively little oversight because that group has certain privileges, it can create bad incentives, especially in poor communities. Grannies in Glasgow sold on their ‘wobbly eggs’ in the 90s in exchange for bingo money.
Like Mnemosyne, I want much better options for people with chronic pain, and I want addiction to be treated with sympathy, but I also want to stop people profiting from pain and addiction, from drug companies down to low-end dealers.
Nate Dawg
Is fibromyalgia real? I’ve always understood it to be a fake illness.
Roger Moore
@gvg:
It is at least connected. A lot of the people who are hooked on opiates got started taking them for chronic pain and wound up either addicted or so dependent on them for pain management that they can’t really function without them. I think that’s why there’s been such a long lead time between when use of opiates was liberalized and when the worst problems started showing up; it takes years for people to develop such a strong tolerance that they need more than doctors will prescribe.
trollhattan
@amygdala:
Wonderful and informative post. Thank you.
Starfish
@boatboy_srq: I think that my NPR told me that heroin overdose has become the third leading cause of death for males in the 25-55 range in the US. (That means more deadly than car wrecks for that age group.) But car wrecks have become less deadly than they used to be.
They are trying to make Narcan more readily available to police, firemen, and schools to reduce death through heroin overdose.
And the pro-legalization Drug Policy Alliance is saying that drug overdose is the leading cause of death for a different age group, and the CDC is saying that four times the number of prescription pain meds are being sold now over what was being sold in 1999, and people are not in significantly less pain for it.
Roger Moore
@Mnemosyne:
Hospice is different, because the assumption is that you no longer have to function in ordinary life with a job, housework, driving, etc.
Starfish
@Bill: I live in a state that has legalized cannabis, and we still have the opioid issue.
Fair Economist
@amygdala: You should lurk less and post more.
Roger Moore
@Nate Dawg:
Yes, it’s real. They have objective diagnostic criteria, and they can measure Substance P (a chemical marker of pain) in patients’ cerebrospinal fluid. It’s likely that fibromyalgia is a syndrome (essentially a shared set of symptoms) rather than a disease (which has both common symptoms and a shared cause), but it isn’t made up or just a bunch of malingerers.
WaterGirl
@Fair Economist: I second that!
boatboy_srq
@amygdala: Thanks for that. It helps to have a professional’s perspective.
@Starfish: Now Presenting Republicans has become part of the problem: too much focus on BSDI, lots of scaremongering, etc. Their statistics may be accurate but the tone has shifted WAAAAY to the Right. After having had my fill of Fauxnews and the rest of the MSM, watching them veer Rightward makes me suspicious. There’s real and there’s “OMFG HAIR ON FIRE DISASTER IMMINENT”, and NPR has veered closer to the latter and the former. Thanks (again) to amygdala for providing some perspective from within the profession.
Interrobang
Who’s prescribing opioids for fucking fibromyalgia or other neuropathic pain? Opioids don’t do anything for neuropathic pain. I take pregabalin for neuropathic pain and it works great. (Amytriptaline is the front-line drug of choice here but it stopped working on me.) I understand that those drugs are mildly scheduled in some countries (not here in Soviet Canuckistan) but they’re less scheduled than the opioids are. It also sounds like American doctors are, for some reason, more inclined to prescribe opioids where non-American doctors would prescribe NSAIDs and physiotherapy, or other similar treatments. (NSAIDs are not unproblematic in themselves, but at least you don’t wind up addicted to them, or having someone else scoop your Celebrex to get high on it.)
An American ex of mine wound up with a massive opioid addiction because basically he was seeing about six different doctors, none of whom was willing to communicate with any of the others, and so they were all writing him prescriptions for different opiate/opioid painkillers (morphine, fentanyl, oxycodone, oxycontin). That kind of thing needs to stop, and would cut down on some overprescribing problems, but part of that issue is structural, in that there are very few general practitioners in the US anymore, so everyone sees umpteen different specialists. (This is not normal, American folks!) The fallout was hell, and part of the reason why he’s now an ex.
nutella
We know that other First World countries have better health care systems than the Rube Goldberg mess we’ve got here in the US. Do they also handle this issue of opioid availability well? Can the non-USians here tell us?
amygdala
Thank you all for the kind comments.
@nutella:
Vancouver has been experimenting with prescribing heroin. Needle exchanges help with HIV, HCV, and other blood-borne diseases, but overdose remains a problem. Supervised administration helps (as does making the opiate antagonist naloxone more ready available to users). Portugal decriminalized drug use over 10 years ago, with good results. Michael Moore discusses that in Where to Invade Next.
It’s worth noting that SE Indiana saw an HIV outbreak last year, driven by injection drug use, as bad as those of the early plague years of the epidemic. Governor Pence deserves credit for responding with science-based policy. Needle exchange seems to have worked, with decreasing numbers of new cases.
Ella in New Mexico
Oh this SOUNDS so good—to someone who never works with actual patients or sees how the existing opioid restrictions have been an undue and mindless burden on otherwise deserving, law abiding people. Real harm has been done because there is no room for discretion as it is now, I can’t imagine how it will be when a cancer patient relocates to live with a family member and is then denied their pain meds because they don’t come from the same pharmacy in their old home town, and they end up in excruciating pain for a month waiting for the new script to be allowed. I see a ton of inpatient admissions with this one…
It would be smarter to finance the creation of a data base in which a physician or pharmacist can log in from any location in the us and see the opiate prescriptions issued to that patient. Then they can see if the patient is truly “Doctor shopping” or actually a legitimate user with varying insurance/financial/ or other geographical circumstances (eg, “snowbirds” who live in two places half the year”)
Once again, laws with strict rules regarding the doctor patient relationship and no discretionary exceptions have tons of unintended consequences–in this case, they hurt legitimate pain patients, causing undue suffering, —and may just send more addicts out to the street for heroin or other more serious drugs.
Ella in New Mexico
@amygdala:
YES.YES.YES.
Thank you for this post. So right on target.
moops
@jl:
The problem is that this is all stick and no carrot for the physician and the patients they are trying to care for.
If you impose single-pharmacy rules, then at the same time get off the back of prescribers and let them prescribe actually meaningful amounts of opiods without threatening their practice.
I already have to undergo outpatient surgery procedures *without* opiods because my doctors are too scared to prescribe anything. I’m not doctor shopping. I have several issues, which cause pain. I can get it filled at one pharmacy, fine. I don’t want flack from the pharmacist, and I don’t want my GP or specialist all taking one step backwards as to who should step up and control my pain.
KPed
@Origuy:
I can easily think of 1 very common scenario where the bill would not work: surgery.
Say a little old lady has bad arthritis and reflux (a fairly common situation). NSAIDs are a bad choice (GI side effects as well as increasing mortality with cardiac issues). Tylenol is a POS drug for pain control. Many are on low dose opoids for arthritis. Say she has uterine prolapse (again, very common), I do a hysterectomy on her. Damn straight I’m going to prescribe narcotics!
Paul in KY
@amygdala: Thank you for that info.