The problems with one-size-fits-all laws on opioid prescriptions

(Source Washington Post)

Presidential hopeful Sen. Kirsten Gillibrand (D-N.Y.) is the latest politician to make the mistake of backing a one-size-fits-all effort to reduce opioid prescribing. Last month, she announced a bill, co-sponsored by Sen. Cory Gardner (R.-Colo.), aimed at addressing the overdose crisis by limiting opioid prescriptions for acute pain to seven days.

Gillibrand was promptly criticized by disability-rights advocates and chronic-pain sufferers. “It’s clearly a well-intentioned bill,” said Julia Bascom, executive director of the Autistic Self-Advocacy Network, who lives with chronic pain, “but anyone who is living this can tell you how quickly it can fall apart in practice.” Others were harsher: “This is NOT the solution,” read one early response on Twitter. “This is a clear doctor-to-patient issue. … What are you guys thinking?”

Taken aback by the criticism, Gillibrand responded on Medium. “I hear you,” she wrote, assuring readers she wanted to make sure health-care decisions remain “between doctors and patients” (although the bill was designed precisely to tie doctor’s hands).

The Gillibrand-Gardner bill is aimed solely at prescriptions for acute pain — such as pain following surgery — and exempts chronic-pain prescriptions from regulation (as well as prescriptions related to cancer treatment and end-of-life palliative care). But patients and activists know that regulation in one area often has unwelcome spillover effects. And the line between chronic and acute pain is not cut and dried: Pain that is symptomatic of chronic illness is often first diagnosed as acute pain.

[I’ve seen the opioid epidemic as a cop. Living it as a patient has been even worse.]

All of which means tackling the overdose crisis with formulaic solutions may do more harm than good.

These two politicians are far from the only ones to propose strict limits on how doctors may prescribe opioids. Sen. Rob Portman (R-Ohio) recently announced he would reintroduce a bill with even shorter limits for acute-pain prescriptions: three days. At least 32 states have enacted limits on access to opioid pain medication, as have numerous private health insurers and several major pharmacy chains.

Regulation of opioid prescriptions has been accelerating since the Centers for Disease Control and Prevention issued guidelines on opioid prescribing in 2016. The guidelines were largely about the treatment of chronic pain but included some observations about acute pain. The CDC suggested acute pain will rarely require prescriptions beyond three to seven days and cautioned doctors about prescribing doses higher than the equivalent of 90 milligrams of morphine daily.

But those guidelines were voluntary and allow for provider discretion if a patient needs longer supplies or higher doses. Policymakers, in contrast, have translated those recommendations into absolute limits.

We have already seen the result of too rigidly applying the guideline in the case of chronic pain sufferers, many of whom have taken opioids for decades. A December 2018 report by Human Rights Watch found that doctors were abruptly reducing or eliminating chronic pain patients’ opioid medication without their consent, even when they believed patients benefited from the medication and were not misusing it.