So in an article in Wired, today discusses a concern not only to pain medicine but to addiction medicine.
APRIL GROVE DOYLE, a 40-year-old single mom with metastatic breast cancer, pulled her car to the side of the road. Her face was flushed and her eyes puffy from crying, but she looked into the phone mounted on her dashboard and pressed the record button.
“So, I’m just leaving my pharmacy,” she said, taking a breath to steady herself. “I’m not, I’m not—I’m frustrated, and that’s why I’m crying. I get pain pills, maybe every two, three months, OK? I can make one monthly prescription of pain pills last two or three months because I don’t really take it unless I absolutely need it. And when you have metastatic cancer in your bones, you need it. Because sometimes the pain is so much you can’t even function. And I just want to function.”
After another deep breath, Doyle explained: The pharmacist at her local Rite Aid pharmacy in Visalia, California, had berated her for her history of opioid prescriptions, then told her to come back later. She left without the refill, feeling that she was being treated like a criminal.
I am going to be blunt as hell here. Pharmacists do not have prescriptive authority (except on a limited basis) so who are you to tell me or my patient they should or shouldn’t get a particular drug. First, it’s birth control, and now you are harassing and/or blatantly refusing? Stay in your lane here pharmacists. You have a job to fill scripts and check for contraindications. A pharmacist is there to counsel people, and to ensure folks know how to take their medications and what to expect for side effects. You are not there to decide who gets what, no matter what. If your conscious is so overwhelmed by doing your job, maybe you should just find another job. You can do what the rest of us do when they are confronted with something we don’t like; suck it the hell up and drive on (always wanted to yell that at people, they don’t usually like that outside of the military)
This next bit is just plain damn infuriating (as if the above is not)
One in four cancer patients have had trouble getting their pain medication because a pharmacist refused to fill the prescription, even though the drug was in stock, according to a survey by the American Cancer Society Cancer Action Network. Thirty percent said they couldn’t get the pain meds their doctor prescribed because their insurance wouldn’t cover the costs.
Suicides are rising among people with chronic pain, according to a 2018 analysis of National Violent Death Reporting System data. Halting opioids suddenly also can lead to cardiovascular problems, including heart attacks, according to Michael Schatman, director of research and network development at Boston Pain Care and editor in chief of the Journal of Pain Research.
See that 1 in 4 CANCER patients. You know that stuff that causes not only severe pain, but has painful and debilitating treatments? I expect insurance companies to deny claims/treatments because quite frankly they don’t want to pay for anything, but once again pharmacists stay in your lane and do your damn job not mine.
Non-cancer chronic pain is a little trickier, of course, and myself, like other providers, have to strike that fine line. We must always look at the whole picture of what is causing the pain. We have to work with the patient on other methods of mitigation, and we need to get past the mindset that there MAY be things better than opiates to treat pain. I emphasize that there may be alternatives. Sometimes you are out of options, and the only way to manage this pain is opiates. Sorry everyone sometimes you don’t get to magically cure shit.
So interestingly, many of these folks are quoting the CDC guidelines for prescribing opiates and applying to everyone. As you all can read; “chronic pain outside of active cancer, palliative, and end-of-life care.” The report says this at least a dozen times, and this table has this line in it, at least 2 times.
The CDC recommendations are here in Box 1 (all the way at the bottom), (the link is to the whole article, and it is long) but I will print them below:
CDC recommendations for prescribing opioids for chronic pain outside of active cancer, palliative, and end-of-life care
Determining When to Initiate or Continue Opioids for Chronic Pain
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
- Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
- Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
- When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
- When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to =50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to =90 MME/day or carefully justify a decision to titrate dosage to =90 MME/day.
- Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
- Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
- Assessing Risk and Addressing Harms of Opioid Use
- Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (=50 MME/day), or concurrent benzodiazepine use, are present.
- Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.
- When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
- Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
- Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
* All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except recommendation 10 (designated category B, with individual decision making required); see full guideline for evidence ratings.
When you look at this list, it seems reasonable. It is really what providers already go by in terms of decision making for the prescription of opiates for all patients. Cancer, palliative, and end of life care are no hold barred prescribing (or should be). Why are we so concerned that someone should not be comfortable with debilitating conditions? Personally, it takes a lot to get me to prescribe an opiate for acute pain unless it is related to a severe injury. There IS a time and place for opiates.
Bottom line: Work with your provider on pain issues. Have honest discussions with them and keep them in the loop what is going on with your opiate use. If you are having difficulties such as breakthrough pain, side effects (constipation is the most common) talk to us. Don’t let it get out of control.
Taking opiates away from folks chronically prescribed leads us down the road to addiction, and no one wants to drive a patient away and to that end.
Lastly, it’s tough, but if you think you are addicted, talk to your provider. There are ways to help and treat your pain.
Sorry for the long one kids, I blame the CDC. That guidance is spouted so often, but very few people see it.