Patients weigh in on opioid cutbacks

In pain, doctors skittish, they say

Proposed opioid restrictions haven’t taken effect yet, but already have prompted some Arkansas doctors to start cutting back on how much pain medication they prescribe, patients told the state Medical Board on Thursday.

Kirk Maynard, 57, of Clinton, said his doctor has reduced his monthly supply of Oxycontin by almost half in advance of the new rules.

“My pain level has went from manageable to roller coaster, just due to what’s likely to come,” said Maynard, whose back was injured when a metal gate fell on him more than 20 years ago.

The proposed rules, aimed at reducing painkiller abuse and overdoses, would require doctors to take extra precautions when they prescribe daily doses of more than 50 morphine milligram equivalents, which is equal to about 10 5-milligram tablets of hydrocodone.

The rules also would

limit prescriptions for treatment of acute pain, such as after surgery, to a seven-day supply.

The limits are based on guidelines from the U.S. Centers for Disease Control and Prevention, which say doctors should “carefully reassess evidence of individual benefits and risks” when prescribing more than 50 morphine milligram equivalents per day.

Under the proposed Medical Board rules, doctors who prescribe that amount would be required to explore alternative treatment plans and document “objective findings,” such as laboratory tests, showing the need for the treatment.

James Spencer, 51, of Cabot, who was injured in an accident involving a tractor-trailer 14 years ago, said his doctor and pharmacist are “scared to death that they’re going to lose their license” because of the prescribing restrictions and requirements for documentation in the proposed regulations.

Since June, his doctor has reduced his pain medication dosage by more than half, he told the Medical Board during

a hearing on the rules.

“My way of life has gone drastically downhill,” he said.

Medical Board member Sylvia Simon, a Monticello family practice doctor, said some doctors appear to be overreacting.

“This is Y2K,” she said, referring to fears about a bug that would affect computers on Jan. 1, 2000. “Everything’s going to shut down because we’re talking about this regulation.”

Simon said it’s a “common misconception” that the board will revoke a doctor’s license based on a single prescription.

Complaints of excessive prescribing are reviewed by the pain-management committee, which makes recommendations to the board.

“The doctor always has a chance to present their side and show us a justification,” Simon said.

Pharmacists and insurance plans also have taken steps to limit prescriptions.

Carlos Roman, an anesthesiologist and chairman of the Medical Board’s pain-management review committee, said one pharmacy last month refused to fill a 30-day supply of hydrocodone for one of his chronic pain patients. Instead, it would fill only a seven-day supply.

That’s a problem, he said, because the patient is on a fixed income, with “limited financial means,” and each trip to the drugstore requires making another co-payment.

In another instance last month, a drugstore refused to fill a Xanax prescription for a patient who had a herniated disk and had just been diagnosed with renal cancer because of a policy against filling prescriptions for benzodiazepines, such as Xanax, and opioids at the same time.

“When this kind of stuff starts to happen, we’ve got a problem, and we as physicians need to stand up for our patients,” Roman said.

State Drug Director Kirk Lane suggested that the Medical Board limit prescriptions for acute pain even more — to a five-day supply, instead of seven days.

Researchers have found that patients who received larger supplies were more likely to become long-term users, he said.

Simon voiced concern that the smaller limit could create a hardship for patients who run out of medicine over a weekend and have to wait until the next Monday to get new prescriptions.

Roman also favored the seven-day limit, saying he doesn’t think acute-pain prescriptions are a large driver of opioid abuse and that he’d rather a patient end up with a few extra pills than not enough.

In response to comments at the meeting, the board will revise a part of the rules that would have required doctors who are not pain-management specialists to consult with such a specialist when prescribing 90 morphine milligram equivalents or more per day, board attorney Kevin O’Dwyer said.

Instead, the rules will reflect the CDC guidelines, which say doctors should avoid or “carefully justify” prescribing such large doses, he said.

The rules will also add nursing-home patients and residents of assisted-living facilities to the list of patients who are exempt from the prescription limits, O’Dwyer said.

Patients with cancer, in hospice or palliative care, or being treated in hospitals or during emergencies are also exempt under the proposed rules.

The Medical Board will vote on the proposed rules after a public hearing in April, he said. The rules will then go the Legislative Council for final approval.