Thursday, March 28, 2013

Chronic Pain, Opioids and Physician Risk

A few weeks ago I posted an opinion that Kentucky was leading the nation in the control of opioids.

Referencing their prescription drug database, KASPER, and a new law, I said opinions of the Kentucky Medical Association, Kentucky Pharmacy Association and Board of Medical Licensure that the new law was "workable" was "a pretty good endorsement for a law that has such broad and sweeping impact."

There are two sides (at least) to every story, and my opinion drew some criticism from some Kentuckians with first hand experience with the law and the KASPER system - their sentiments essentially were that Kentucky law (HB1) went too far, and that doctors now are too scared to prescribe ANY pain medication.

Here are some of the (edited) comments.

Justin wrote:

"I think someone should tell all the doctors in Kentucky that are refusing to treat chronic pain patients (even ones with clean KASPER's) since HB 1 (2012) was enacted that: 'the major players are, if not happy with the end result, at least are not unhappy with it.' and 'The Kentucky Medical Association, Kentucky Pharmacy Association and Board of Medical Licensure have indicated that the changes made by HB 217 are workable.' Because to a chronic pain patient in Kentucky who is unable to get their pain medications since HB1 was first enacted back in July of 2012, HB1 is pretty flippin' far from 'workable'!

"Since HB1 was passed in July of 2012, people in pain from all walks of life and from all kinds of circumstances have been unable to get treated for their pain! This includes chronic pain patients, emergency room patients, and even some hospice patients (which are some of the reasons why HB 217 was passed so darn quickly!). Chronic pain patients who have been going to the same doctor for years, who have taken the same medications for years without incident, and who have clean KASPER’s, can no longer get their pain medications because of HB 1! Doctors all over KY are now afraid of losing their license or being investigated by the DEA because of HB 1- they have been dropping their chronic pain patients left and right because they are afraid to prescribe any kind of narcotic to anyone for any reason!"

"HB 1 is a piece of 'shotgun legislation.' It was not well thought out, it had little input from the medical community, and no input from the people affected most by this heinous law- the chronic pain patients that depend on these medications for a certain quality of life! HB1 punished the many innocent for the acts of the guilty few!"

Laura added:

"HB1/HB217 does not address the needs of patients with chronic pain. While prescription drug abuse does need to be curtailed in Kentucky, this law passes the consequences of drug abuse from the abusers onto the backs of law abiding citizens and hard-working Ky families."

"Law abiding citizens who are the victims of violent crime, bad medicine (such as the rash of faulty female reproductive appliances such as Mirena and the Vaginal Mesh, and faulty replacement hips), and injured veterans should not have to suffer in pain or be treated like criminals because they need pain care."

Kim said:

"Not aware of any lab tests or diagnostic studies that can confirm three of my diagnoses: fibromyalgia, restless legs syndrome, or interstitial cystitis. Where would that put me in the "angry patients" theory that sorts out the fakers by confirming their need for pain medications through lab and x-ray results?"

Shiela wrote:

"This law was aimed at stopping abuse which is a great idea, however I do not think law makers thought this through on how it would hurt many many people. When people have had TEST AFTER TEST (TESTS SUCH AS MRI'S CATS SCANS, PET SCANS, EX-RAYS, ULTRA SOUNDS, ECHO'S ECT DO NOT LIE) to prove they have the medical condition in which they need medication for and Doctors will NOT even allow them to come to their office due to fear this law has created is a travesty. I for one have seen many many people suffer, including a family member that received a organ transplant and was allowed 3 days worth of pain medication after being released from UK hospital."

ewoods commented:

"The doctors should not stop treating patients just because they are being asked to run backgrounds on people. As soon as the law was signed my doctor refused to help me with my pain anymore. So why is it we have to suffer while the doctors can turn their back on us patients, and for those of us with no insurance we cannot afford to go to a pain clinic and there are very few that accept cash."

Sick & Tired stated:

"Lawmakers obviously didn't consider the suffering of cancer, hospice/end of life and surgery pain to begin with. Are we to assume they didn't have the knowledge or do they lack compassion or both? It's scary to think they're deciding who suffers and who doesn't. ... I've never been to a pill mill but thanks to HB 1 my legitimate doctor can't prescribe this legitimate chronic pain patient with the small amount of medication that helped make life worth living without too much suffering."

Perhaps its serendipity, but a recently introduced California bill, SB 410 (Leland Yee, D-San Francisco), would give state physicians immunity from disciplinary action for prescribing and dispensing dangerous drugs to treat chronic pain.

The bill, which is sponsored by the California Society of Anesthesiologists, would amend Business and Professions Code Section 2241.5 to say, “A physician and surgeon may prescribe for, or dispense or administer to, a person under his or her treatment for a medical condition dangerous drugs or prescription controlled substances for the treatment of pain or a condition causing pain, including, but not limited to, chronic pain or intractable pain.”

Presently the Intractable Pain Law, which was enacted in 1990, says a physician should exercise “reasonable care” to determine when a referral or consultation with a more qualified pain or addiction specialist is necessary. It also notes that “no physician and surgeon shall be subject to disciplinary action for prescribing, dispensing or administering dangerous drugs or prescription controlled substances in accordance with this section.”

The opposition to SB 410 says that under Yee’s bill, a doctor could prescribe narcotics to anyone who reports any kind of pain, not just to cancer patients or patients with other terminal diseases.

The debate, the experiences of those in Kentucky, the difficulty in drafting laws to accomplish reasonable controls over pain medication while still providing adequate enforcement provisions and protection of patients, shows how incredibly difficult it is to accommodate the needs of society.

The problem is a uniquely complex balancing of the needs of law-abiding, chronic pain sufferers seeking some semblance of quality of life versus unscrupulous profiteers with no respect for the law or the health of individuals.

I don't have a solution. I do appreciate the complexity of the issue and it is likely that many others, such as those who took the time to write me from Kentucky, will be unnecessarily adversely affected while the profiteers find some other way to advance their own interests.

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