Perusing the paper this morning brings me to a New York Times article: Good news: Opioid Prescribing Fell. The bad? Pain Patients Suffer, Doctors Say. In short, my response is, I am not surprised since I spoke about this when I started the blog. This one is likely to be a tad preachy so hang on kids because taking away pain management techniques is crap.
The CDC Issued recommendations in an All Call letter to providers stating they should restrict a patient to 90 mg of morphine equivalents (MME) per day. To give my gentle readers (except you Karen you psycho) an idea 100 mg ME is equal to 100mg Hydrocodone (Lortab), 25mg Hydromorphone (Dilaudid), 65mg Oxycodone (Percocet), or 37mcg fentanyl (this is why everyone is worried as hell about fentanyl because you can easily overdose). That dosage should only be maintained for a maximum of 90 days. So where are the chronic pain folks in this, they are screwed because many of them are on much higher daily doses. These doses are really tweaked to give the patient the most benefit from the least medication possible. Add to all of this the “walk of shame” most go through at their provider’s office, “they aren’t really in pain,” “why do they get so much?” Nurses and ancillary staff can be some serious bitches sometimes. Many folks literally beat up by providers to ensure that they are actually in need of opiates at that or higher doses.
So, Insurance has taken this as a “rallying call” to limit the amount covered. For many insurance carriers they have set the limit based on the CDC guidelines, which is not a law, but hey anything to look like you are “helping” (you aren’t). The CDC is amazing, but they missed the boat on this one. The Trump administration was even near the ocean on this with just a 30,000 statement of, “we’re going to fix the opiate problem” Their solution? Prescribe less. Yeah, no shit genius, but it doesn’t work that way. We are treating patients not making automobiles, steel, or a coal mine. Magic thinking doesn’t work here, and you can’t say only this many people should have them and expect it to magically happen, However…
Pharmacies and Insurance providers have taken it upon themselves to limit the amount dispensed to a 7 day, or 10-day max fills on an opiate prescription. They decided to do that, it indeed isn’t those of us that frequently deal with patients who have chronic pain issues. Look I get it, opiates can certainly be addictive and misused, and we as providers need to take safety steps in prescribing and we need to ensure that the patient is educated in reporting issues to us. I’m the guy that busted his ass for 3 years to get to this degree, I should know enough to sit with my patients to or effectively assess them or consult them to see an addiction medicine specialist to evaluate addiction potential.
Addiction is a behavioral maladaptation where the medication takes over their lives, and yet they continue consequences be dammed. We should look at this, not for our protection, but for the whole do no harm thing we agree to when we accept our degrees. We should always put the patient’s safety in the spotlight. With most chronic pain patients, that spotlight is well defined, and we very quickly learn to look at those worrisome tendencies. All chronic pain patients are not addicted.
Setting a guideline and goals for over prescription is admirable, but it is not a law, it is not an absolute, it is a guideline. If I could magic away people’s pain… but alas we are stuck with the best medications that we can do to alleviate this, sometimes those are opiates. All this from a man and his administration who could give a rat’s ass about healthcare because their base “thinks” it’s an unnecessary expense. Somehow this clueless idiot thinks that opiate scripts should be “limited?” Oh, for the love of Karianne. The kid whose parents racked up the 500k bill from tetanus? Hope they had good insurance because that is a big freaking bill.
Bottom line? Not the way to handle the opiate crisis and we are hurting people because we have to have a magical number, why? Look I get the idea we don’t need tons of folks using prescription opiates that don’t need them. Do we, however, must decide one person that puts us over the magical quota?
The healthcare system I work for has a committee that looks at the break down of Morphine equivalents by providers and essentially makes them explain if they prescribe more than 90 MME. While it is reasonable for the group to look at the providers, I am still back to the arbitrary guideline.
The answer? We are lazy. Someone came up with a metric, and everyone lost their damn mind. I can hear insurance boardrooms now, “Well the government says 90 is enough, so let’s roll with that.” Trust Nursie poo, he has sat in those rooms and watch Doctors and nurse case managers argue about bed days and treatment modalities. This makes it easy but was not brought down from the mountain in stone, so we need to think about this.
To the credit, 300 providers have asked the CDC to basically, “show their work,” reconsider limits and find a better solution to help those patients with chronic pain. Do more research, which the CDC is doing. I realize there needs to be a get it done statement, but the administration is clueless and could give a damn less about it.
We can’t be rigid. Take a doctor I used to work with, we’ll call him Dr. S. Dr. S hates opiates and in fact, won’t prescribe them. He sites a lot of the crap above, but he knows people have chronic pain. He refers these folks to the pain clinic, but why not work with a patient to help him with pain until then? (pain clinics sometimes have a 90-120 day wait time). Simple he sits on the hospital committee that oversees this and feels the stress coming about MMEs, and he doesn’t like the idea of being in the hot seat (his words). He is one of several that won’t prescribe opiates. One doctor takes pride in not prescribing them at all, and in fact, will often cancel even pain clinic referrals because he refuses to deal with them at all. Ugh.
The Bats rolled out to Sonoma for a quick wine tour today they avoided flying on a 737 8 Max, so there is that.