A Wrong Turn in the Fight Against Opioid Abuse
Oregon's move to end Medicaid coverage of the drugs for many chronic-pain patients is a bad idea. Let's hope it doesn't spread.
Oregon is considering a proposal that would make it the first state to end coverage of opioids for many chronic-pain patients enrolled in Medicaid. Beginning in 2020, patients who use these medications under medical supervision to live productive lives would have 12 months to get off of them all together.
These restrictions go well beyond what has been suggested by the U.S. Centers for Disease Control and Prevention. Nowhere in its guidelines does the federal agency suggest cutting pain patients off from opioids after a year or at any time.
As a pediatric nurse practitioner on the frontlines of caring for patients in chronic pain, I know -- and every doctor, nurse and emergency worker knows -- that this plan will make things worse for many of those who must cope with chronic pain. And the direction Oregon is headed leads me to fear that other state Medicaid programs will follow suit.
We have had years to observe the impact of well intentioned regulations that limit opioid prescribing. Walmart, Anthem and CVS have restricted prescriptions for pain patients, and at least 33 states have passed laws limiting opioid prescriptions in some way, according to the National Conference of State Legislatures.
But while opioid prescribing has dropped, rates of opioid misuse and overdoses have continued to rise, which suggests that limiting or cutting coverage of these medications isn't working. Such actions, and especially what Oregon proposes, may actually fuel the opioid epidemic, increasing both health care costs and death rates. We're likely to see people without medication seeking emergency care; increased suicide rates for people with chronic pain; people leaving the workforce because they no longer can get the medication they need to help them live productive lives; and people turning to street dealers to treat their pain.
Some steps aimed at curbing opioid misuse make sense. Walmart, for example, distributes free opioid disposal bags, supports the dispensing of naloxone and sells medication lock boxes to help keep opioids out of the hands of family members and others who haven't been prescribed the drugs. These are good moves.
But lawmakers and many big health care businesses seem to think a one-size-fits-all solution -- reducing or ending access to opioids -- is the answer. That's unconscionable. A doctor wouldn't stop a medication that keeps a heart patient alive or cut off insulin for a person with diabetes. Why, then, would we inflict such a drastic approach on a person in persistent, excruciating pain?
Patients with chronic pain often have limited treatment options because insurers refuse to cover many non-opioid treatments. In some states, laws prevent patients from getting medication for more than seven days at a time. These kinds of restrictions add further stress to people who are already suffering. Some patients say they'd rather die than live with the alternatives they've been given.
Since the CDC published its guidelines in 2016, attention has been laser-focused on restricting access to legal prescription opioids -- as if there is no other solution to this crisis. There are alternatives to opioids, including multidisciplinary pain care programs that offer rehabilitation, cognitive behavioral therapy, other non-drug treatments, and nursing support and coordination. We should be paying more attention to -- and investing in -- these and other alternatives. But that shouldn't mean that people who genuinely need the pain relief that only opioids can provide should be denied them.
There's no real bad guy here. The crisis we face results in large part from mismanagement of the very people we want to help. What we need is balance. Nurses who care for people in pain every day, together with physicians, pharmacists, psychologists, rehabilitation professionals and others, should partner with each other and their patients to better manage pain while minimizing the risk of opioid misuse. Health care professionals, patients and the public need to be educated on safe and effective pain control.
We can do this, but not if we are limited by rules that are against our better medical judgment. Millions of people in chronic severe pain need help. Let's not force them to drug-seek on the streets.