POLITICS OF PAIN
As state limits prescriptions, patients worry about access
Two decades ago, the Valcarcels’ lives changed in an instant. Jim Valcarcel and his wife, Dorothy, were nearly home from a Los Angeles business trip when a Nissan Sentra jumped the Interstate 10 median at 51st Avenue and crashed head-on with the Valcarcels’ BMW sedan. The Nissan’s driver died immediately. Jim and Dorothy Valcarcel each spent four months in a hospital with severe trauma. Jim Valcarcel’s injuries were life-altering. His legs shattered into bits of bone. His right leg and right hip were reconstructed with metal screws and plates. He often uses a cane to walk.
“I am going to have to learn to live on less medication.” Jim Valcarcel Chronic-pain patient, on new restrictions on opioid prescriptions
“Doctors have categorized me as totally disabled,” said Valcarcel, 63, of Cottonwood. “The reality is: I can walk. I can drive. I come down to (Phoenix) once a month and see my pain specialist.”
But the pain never leaves. He manages it with a regimen of powerful pills prescribed by his doctor, J. Julian Grove, a specialist at Phoenixbased Pain Consultants of Arizona.
Valcarcel said his biggest worry isn’t the injuries sustained two decades ago. Like many chronic-pain sufferers across the state and nation, he frets about whether he’ll have access to pain-relieving medication as policy makers pass laws that limit prescriptions to curb an opioid epidemic that accounted for most of the nation’s 64,070 drug-overdose deaths in 2016.
In Arizona, Gov. Doug Ducey declared a public-health emergency last year and directed the Arizona Department of Health Services to complete a report with recommendations on how to slow the epidemic.
That led to an Arizona Legislature special session this week for a bill called the Opioid Epidemic Act — legislation that would limit initial pain-pill fills to five days for “opioid naive” patients and impose a dosage limit for many others seeking new prescriptions.
Ducey’s bill followed the Arizona Department of Health Services’ opioid action plan, released last fall, that recommended prescribing restrictions, tougher oversight of pain-pill dispensing, continuing medical education for doctors and treatment for people battling addiction.
Ducey, legislative leaders and state health officials said the overriding goal is to save lives.
Arizona health officials said more than two Arizonans died every day, on average, from opioids in 2016.
As part of the Republican governor’s emergency declaration last year, law enforcement, emergency medical technicians and health care providers must report all suspected overdoses and deaths within one week.
The running tally is displayed prominently on the state Health Department’s website: 816 deaths, 5,377 overdoses and 530 babies exposed to opioids in the womb since June 2017.
The figures collected since then suggest the opioid death rate may have accelerated compared with 2016, though officials cautioned the numbers are preliminary. The state won’t be able to confirm the deaths are the result of opioids until county medical examiners analyze toxicology tests and complete investigations.
The problem has been two decades in the making.
Powerful new drugs like OxyContin hit the market in the mid-1990s, and doctors were increasingly encouraged — in some cases mandated — to assess a patient’s pain levels during appointments.
State leaders believe new laws and regulations are desperately needed to prevent more addiction and treat those who now are dependent on prescription pain pills. Four out of five heroin users began by using prescription opioids, state officials said.
Ducey’s Opioid Epidemic Act caps the dosages of opioids that most new patients can take each day. But the bill would allow people now on pain pills to ask their doctor to extend existing prescriptions.
“We don’t want to limit patients’ access to the medication that they need to control pain,” said Cara Christ, director of the Arizona Department of Health Services.
Valcarcel said for a decade, his pain medication did not change.
Three times a day, he would take a 60 mg pill of the powerful painkiller OxyContin — one pill every eight hours. His doctor also prescribed Percoset for breakthrough pain.
But this fall, his doctor said his daily dosage was too high. He would need to taper his pain medication to one-third of what he had taken for the past decade.
Last September, the ADHS released its opioid action plan, which recommended a maximum dosage of 90 morphine milligram equivalents, or MME, per day for most people. The reason: Risk of overdose for prescriptions at that potency is 10 times higher than with lower opioid strengths.
Arizona is one of more than a dozen states that have either recommended or required maximum dosages. These state plans are largely built off Centers for Disease Control and Prevention guidelines issued in 2016.
The measure, MME, varies based on the type of opioid. The limit for oxycodone, the active ingredient in OxyContin, would be 60 milligrams each day, according to the CDC.
“They are withdrawing my medication, slowly but surely,” Valcarcel said. “I am going to have to learn to live on less medication.”
Valcarcel said that his doctor reduced his third daily pill of OxyContin to 40 milligrams, with the other two pills remaining at 60 milligrams. When he returns to the doctor next month, he expects his prescription will be reduced to two daily pills at 40 milligrams and a third at 60 milligrams.
He said activities such as walking have become more laborious since he began tapering.
Because Ducey’s opioid bill did not adopt the ADHS recommendation that most people taper from high dosages, Valcarcel said he is hopeful that his doctor will change his care plan during next month’s visit.
Citing patient confidentiality, Pain Consultants of Arizona could not discuss care provided to any patient at the Phoenix pain-management clinic, said Jason Moore, executive director of the medical practice. Grove, Valcarcel’s doctor, did not return multiple calls from The Arizona Republic.
Two doctor groups, the Arizona Medical Association and the Arizona Osteopathic Medical Association, both urged the Ducey administration to introduce a bill that does not require existing pain patients to taper dosages.
Many patients on high dosages of pain medication can function and be productive under proper care, the doctor groups said in a December letter to the ADHS.
“Imposing this type of a requirement on healthcare delivery would create arbitrary sub-classes of patients and likely result in unnecessary and disproportionate patient suffering,” the letter stated.
Valcarcel said he believes that chronic-pain patients like him are being unfairly targeted as states combat the opioid epidemic.
He acknowledges many heroin users started on prescribed pain pills. But he said that it’s unfair to impose new restrictions on chronic-pain patients who have followed their doctors’ recommendations for years without a problem.
“We are being treated as if we are guilty until we prove we are innocent,” Valcarcel said.