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Cedar Rapids, Iowa 52401
Pain hurts. Chronic pain hurts all the time. It’s an ever-present demon that lurks in the background waiting to ruin everything for whoever it afflicts — their mood, their plans, their career, their quality of life.
I’m one of those for whom that demon lurks. If you are a regular reader of my column, you’ve likely read before that I live with chronic arthritis. I hate to appear over-dramatic, but it’s excruciating. My rheumatologist and I treat my pain with a medication containing a combination of acetaminophen, a non-narcotic analgesic more commonly known as Tylenol, and hydrocodone, an opioid. I’ve taken it one or more times per day for 17 years. Your friendly neighborhood opinion columnist is a pill-popper.
Opioids work by binding to certain receptors in the brain, temporarily dulling a person’s perception of pain and bringing a sense of relief that can feel … fairly nice. To some, “opioid” might be a scary word. The vast majority of opioid-related media coverage focuses on its dangers — addiction and abuse — and actions intended to curb them. From the politics surrounding the issue, it’s easy to conclude that there is no good purpose for the use of opioids. Rarely, if ever, are the stories told of people with diagnosed, chronic conditions for whom responsible use of opioids is vital to their ability to function.
For me, like millions of other Americans in chronic pain, prescription painkillers have proved safe and effective. I’ve been well-educated on the dangers of misuse. I regularly communicate with my physicians about my usage. Never have I taken the medication more frequently than prescribed. Never am I antsy about making it to the next pill. Occasionally, I even realize that I’ve forgotten to take a dose and feel a bizarre sense of satisfaction knowing that my thoughts and actions aren’t consumed by such a habit-forming drug.
Even the most responsible of “legacy” patients — those prescribed high-dose opioids for a prolonged period of time — develop a physical dependency on those medications from long-term use. Abruptly discontinuing them could cause “serious harm,” according to a 2019 communication from the FDA, such as “withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.”
My psychological health is sound. I intend to keep it that way, so I take the potential for harm seriously. It is therefore in my best interest to ensure that I remain able to access my prescribed medication. But obtaining that medication has only gotten more difficult over the last eight years.
In 2014, the Drug Enforcement Administration, or DEA, used its rule-making power aggressively by moving hydrocodone combination products (HCPs) up the schedule of controlled substances created by the Controlled Substances Act of 1970. Previously, HCPs were defined as a Schedule III controlled substance. Physicians were able to submit prescriptions by phone or fax and include up to five refills in a six-month period. By reclassifying HCPs under Schedule II, pharmacies could no longer dispense those substances without a written prescription, nor could physicians include refills in those prescriptions.
At face value, that seems fairly straightforward. But as I’ve theorized before, a rule’s intent and its effect are two separate things. The intent of making HCPs more difficult to get was to prevent misuse. It hasn’t worked. Between 2013 and 2017, opioid-related overdose deaths only increased at a higher rate. By 2020, they had more than tripled to 68,630 from 21,089 only a decade earlier in 2010. Last year, an estimated 75,673 Americans died from opioid overdoses.
Notwithstanding the original intent of restricting the dispensation of HCPs, the effect was to leave patients in a bind. Many were oblivious to the changes until they visited their pharmacies seeking routine refills only to be told that their prescriptions were canceled (as I experienced In Sept. 2014.) Clinics experienced a sea change in their administrative processes. Legacy patients who were only seen 1-2 times annually suddenly had to obtain new prescriptions each month. Those living further away had to choose between driving long distances to collect each one or wait for it in the mail. One of mine, mailed directly to the pharmacy, never arrived, leaving me set to run out of pills during a long holiday weekend while the clinics were closed. The advice of the on-call physician over the phone was to obtain an emergency prescription the ER, which I did, feeling like a drug-seeking loser.
My days of scrambling to obtain a paper prescription are behind me. In 2018, the state of Iowa passed HF 2377 which in part requires all prescriptions — for controlled and non-controlled substances alike — to be electronically transmitted from the practitioner directly to the pharmacy. The law also added new requirements for physician participation and reporting in the Iowa Prescription Monitoring Program, which was created in 2009. Like my pharmacist, my physician is now required to report specific details about my HCP prescriptions to the state, including my identity, the type of medication, the quantity, and the dates it is described and dispensed.
I’ve never been pleased at the idea of the state keeping tabs on my personal prescriptions. But people are good at setting their principles aside when it is palatable to do so, and I found the welcome end to the years of chasing down paper prescriptions to be quite appealing.
Barriers to obtaining opioid prescriptions don’t stop at government rules. Insurance companies have gotten in on the fun by enacting their own requirements, called “prior authorization.” Without a form signed by my physician, as I was abruptly informed one day, my insurance company was only willing to cover seven days’ worth of my 30-day prescription. I had three options: Wait to fill the prescription until my physician submitted the requisite form to the insurer, pay a steep out-of-pocket cost, or accept one fourth of the originally prescribed quantity and seek an additional prescription to cover the rest of the month. (As hydrocodone products remain Schedule II controlled substances, they are barred from being refilled.)
For some insurance companies, a request for prior authorization can take up to 15 business days — over two weeks — to be approved. Once approved, it usually must be resubmitted once per calendar year. The process has shown to be so burdensome to obtaining medication in a timely fashion that according to a report from the Legal Action Center, 21 states and the District of Columbia have enacted laws as of 2020 prohibiting insurers from requiring prior authorization for opiate-based medications such as methadone that are used to treat substance use disorder. Opioids prescribed for pain control are not subject to those protections.
America has good reason to fear opioids. We can place blame on pharmaceutical companies who misled the public on the risk of addiction while peddling their products, doctors who overprescribed without proper care or consultation, and patients who diverted their prescriptions for illicit use. Patients should not be the one to pay for their mistakes. Prescribing guidelines issued by the CDC in 2016 have led to a sharp decline in the number of prescriptions written for opioid painkillers, denying an untold number of chronic pain patients the relief they desperately need. Meanwhile, overdose deaths only continue to rise.
Those who continue to advocate for the restriction of opioids imply that there are worse things than pain. Those who are in pain know better.
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