New pain-management rules leave patients hurting
Washington state's ambitious new pain-management rules are meant to curb prescription-drug overdose deaths, but some doctors and clinics are just saying no to narcotic pain medications, leaving pain patients with little relief.
Seattle Times health reporter
Denis Murphy's last doctor got suspicious when he saw him sitting in a restaurant.
Murphy, 72, who contracted a painful nerve disorder after a case of shingles, had told the doctor his condition is so painful he often has to stand up.
At his next appointment, the doctor accused him of flimflamming him: making up a story to score narcotic pain relievers.
Murphy, a retired IRS pension-plan examiner and manager from Edmonds, was humiliated. Now, he has a new doctor and a new prescription — but also a growing fear that he could suddenly lose the only relief he's found in six years.
Then, he worries, he'll find himself back in the throes of pain he describes as "a blowtorch to my testicles."
He has reason to worry.
Over the last several months, an effort in Washington to curb a steep rise in prescription-drug overdose deaths — the most ambitious crackdown in the nation — has prompted a number of doctors and clinics to stop taking new chronic-pain patients on opiates, and in some cases to cut off current pain patients.
The hard new line marks the end of a period of relatively liberal — some would say lax — prescribing that began in the late 1980s.
Before then, studies showed that pain was being seriously undertreated, even in dying patients. The statistics and stories fueled assisted-death campaigns in Washington and Oregon and prompted medical boards to reassure doctors not to fear discipline for relieving pain.
But as opiate prescribing increased, so did the deaths — to alarming levels.
Last year, Washington lawmakers attempted to reverse the trend, requiring licensing boards to craft tougher rules for treating pain patients, except for those with injuries, surgery, cancer or who are dying.
The rules don't take effect until Jan. 1 but already, many doctors say they will mean a lot of work, requiring them to gather records, check emergency-room reports, sign pain contracts with patients and arrange consultations as they try to assess an invisible affliction.
For now, the effort has engendered more questions than answers.
Are doctors simply using the new law as an excuse to dump pain patients, who can be needy and demanding — and, in some cases, addicted?
Will the new rules cut down on overdose deaths — or just make life unbearable for the many patients who are legitimately hurting?
In the South Puget Sound area, a University of Washington Medicine neighborhood clinic stopped taking new chronic-pain patients on opiates about two months ago, after patients flooded in, saying their doctors had cut them off.
"A lot of it is because other providers have stopped doing it," said Dr. Peter McGough, chief medical officer for UW Medicine's Neighborhood Clinics. "I think there's been a fair amount of patient abandonment going on."
McGough calls the new law and rules helpful and important, saying many pain patients weren't previously well managed.
"That said, a lot of physicians are saying it's more trouble than it's worth, so I'm just going to send my patients away."
The swift reaction by doctors and clinics to the new rules has startled even critics who expected some negative fallout for patients.
"We did not see coming that entire hospitals, ERs and clinics would have anti-opioid policies coming down the pike; we didn't see that coming," said Elin Björling, Washington state policy specialist for the American Pain Foundation, a patient-advocacy group.
Request to amend rules
Two large statewide physician groups have asked the state's medical-licensing board to amend the rules, saying they are so detailed that doctors could face discipline or legal liability if they don't dot every "i" and cross every "t."
The result, warned the Washington State Medical Association and the Washington Academy of Family Physicians, likely will be that many doctors simply refuse to see pain patients. The board has declined to act.
Dr. Carl Olden, head of the family practitioners' group, said pain-management specialists in Yakima are overwhelmed with pain patients, particularly those on Medicaid, who say their primary-care doctors no longer prescribe the meds they seek.
Linda Van De Bogart, 62, an Eastern Washington resident who has an often-painful genetic defect called Ehlers-Danlos Syndrome, as well as ADD, has been on pain meds for 25 years.
But after being dismissed by her doctor when she and her husband had fallen behind on their clinic bills, she's had no success finding a new provider after calling dozens of doctors and clinics, she says.
"This law has got to be unconstitutional," she says. "It's taking away my life."
Dr. Robert Stevens Singer, a Kirkland neurologist, said he, too, has seen an increasing number of headache-pain patients saying their doctors stopped prescribing opiates. He understands why that might happen.
"It's kind of like saying 'We are no longer going to let you eat liver anymore,' " Singer said. "You didn't want to do it in the first place, and now you've been given an opportunity to escape."
Lax prescribing seen
What lawmakers wanted to do was to stop the dying.
The graphs and charts were ominous, and testimony by Dr. Alex Cahana, head of the UW's Division of Pain Medicine, among others, drew a grim picture of patients addicted or dying from lax prescribing.
Cahana, chief proponent of the new regulations, thinks many doctors have been too quick with the pills, in part because they have little training in other modes of relief, a situation he is working to change at the UW.
"Since when does good pain management equal opioids? Since when has the whole practice been reduced to just prescribing a pill?" says Cahana.
"The U.S. is the only country in the world where overtreatment is the new undertreatment."
In a report this year, the federal Institute of Medicine estimated that chronic pain affects 116 million American adults and that relieving it should be a national priority.
But on the ground, practical realities rule.
At Country Doctor Community Health Centers, Dr. Hal Moore, clinic site director, said providers decided they were spending too much energy on pain patients.
"Is the pain real, are they drug seeking, is mental health a factor? There are all these factors you have to consider," he said, and the rules added another layer. As a result, Moore said, new pain patients no longer will get opiates at those clinics.
Dr. Marcus Rempel, medical director for Neighborcare Health, said providers were disturbed to find that many of the patients inundating its six local clinics seeking narcotic pain relief weren't 50- or 60-year-old workers with back injuries, but young adults of 25 or 30, asking for long-term opiate medication.
"We felt like we were in a situation where we were contributing to a public-health problem," said Rempel, whose clinics closed to new pain patients on opiates.
Community Health Care's five Pierce County clinics stopped prescribing opiates for most new or current chronic-pain patients after two died last year, said Dr. Jeff Smith, medical director.
Other providers say they'll still see pain patients, but under stricter conditions.
"Anyone who says there's not a problem out there has their head in the sand," says Dr. Warren Fein, primary-care medical director for Swedish Medical Group.
The regulations have prompted a new, standardized opiate policy there, adding paperwork such as patient contracts and requiring urine tests for all pain patients.
Fear of being cut off
For some pain patients, the changes are unnerving.
"I'm living in fear of cutoff," says Denis Murphy, despite being what his wife, Judy Murphy, calls a career rule-follower with no history of abuse.
He understands that doctors are afraid of being disciplined, so he endures the random urine tests, although "at the age of 70-plus, it's no fun to go down to one of these druggie centers and stand in line with all these guys with tattoos and pee in a bottle."
Judy Murphy recalls the day in the previous physician's office when her husband was mortified by the doctor's suspicion. "I thought Denis was going to melt into this puddle of humiliation," she said. "He was ready to run or cry or dissolve."
Others say they know they need to reduce their medication but say they haven't been given help to do so.
Eric, a Mercer Island father who has had severe back pain for years after several failed surgeries, said he wants to cut back on his opiate dose but doesn't know how he'd get pain relief during the process.
"When I don't have my pain meds, I sit in the corner shaking and doubled over in pain that makes me cry," he said.
Some statistics hint that a more targeted approach might be more fruitful.
In King County, UW researcher Caleb Banta-Green has shown that the vast majority of prescription-overdose deaths aren't from single prescriptions but narcotics combined with other drugs or alcohol.
Across the state, more than half of those who died were patients on Medicaid, according to state figures, and the most common pain drug was methadone, increasingly prescribed for Medicaid patients after the state restricted other medications.
Many providers said they expect the new rules will ultimately prove helpful but worry that some patients may try risky alternatives in the meantime, taking dangerous levels of acetaminophen or ibuprofen, or even buying opiates on the street.
"It happens, and it's a scenario I've heard too often," Banta-Green says.
Dr. Kimber Rotchford, a Port Townsend pain and addiction specialist, puts it bluntly: "The new law promotes the illicit traffic of opioids" while doing nothing to increase access to mental-health help or alternative pain-relief treatments.
Legitimate patients should not be held hostage to "a few losers," says Singer, the neurologist. "What we need is some balance here."
By Carol M. Ostrom
Jplaw-"Is this knee jerk reaction? What are people going to do that legitimately need pain medicine? This is happening everywhere and it scares the hell out of this pain management patient".