On September 21st, CVS Pharmacy announced a significant change in their policy regarding prescription opioid painkillers. According to CVS, “this program will include limiting to seven days the supply of opioids dispensed for certain acute prescriptions for patients who are new to therapy; limiting the daily dosage of opioids dispensed based on the strength of the opioid; and requiring the use of immediate-release formulations of opioids before extended-release opioids are dispensed.” This new policy is of great concern to people with chronic pain and complex medical conditions who see it as another attempt to solve the problem of opioid abuse with a one-size-fits-all policy change in the continuing “War on Opioids.”
As a person with Crohn’s Disease who has experienced several complications – from abdominal surgeries to a bout of osteomyelitis – I have needed access to powerful opioid painkillers for nine years. As such, CVS’s new policy is concerning for me, because it’s unclear how it will apply to someone like me, who doesn’t need constant access to opioids like other pain patients, but has needed them for treatment of severe pain in the past. Since the complications for which I’ve needed opioid prescriptions are separated sometimes by years, will I be considered a “patient new to the therapy” with “acute pain,” even though the severity of my pain lasts longer than a week and I have taken opioids in the past?
I’m not the only one concerned about how pharmacists will be required to distinguish between acute and chronic pain. Andi Shechter has lived with chronic pain her entire adult life and has taken opioid painkillers for serious spinal problems for decades. “How can anyone judge ‘acuteness?,’” she asks. “Saying that a pain that lasts for seven days is ‘acute’ and anything else is chronic is arbitrary and pointless. My body does not know what day it is in terms of pain. It receives medication and the pain is eased.” Thinking of the long history of doctors changing medications to treat her condition, she asks “how does a pharmacist know any of this? And how can anyone counsel anyone without that knowledge?”
Proponents of CVS’s new policy will argue that people limited to seven-day prescriptions can simply go and get another one from the doctor if the pain persists, but that puts even more of a burden on a patient who is unwell. For those of us with complex health conditions, we already spend hours a week in doctors’ offices and on the phone with insurers and billing departments, have limited access to transportation, and are already hindered by pain and fatigue that limits our ability to juggle all of these tasks. And while some doctors may request exceptions to the policy, in the increasingly tense atmosphere of the “War on Opioids,” many doctors may adhere to the restrictions, regardless of the impact on their patients.
Creating policies that limit patients’ access to pain management isn’t just a burden on these patients, it’s also misguided. According to the National Survey on Drug Use and Health, 75% of opioid abuse originates with people to whom the medication is not prescribed. Rather it’s friends or family of prescription-holders, or those who buy from a dealer. Furthermore, among chronic pain patients, opioid misuse and overdose is relatively low, with about an 8% to 12% rate of addiction among patients taking opioid painkillers for chronic pain. And in a study of 136,000 people who have overdosed from opioids, only 13% were identified as having a chronic pain condition.
Instead of focusing on regulations to decrease the availability of opioid prescriptions to those who do not tend to abuse them, perhaps it would be better to focus on expanding access to addiction treatment and recovery.
Unfortunately, access to these programs is threatened by the current priority of some legislators to cut and cap Medicaid spending. Medicaid plays a significant role in access to treatment for addiction, especially for poor and disabled people. Just as private insurance companies experienced a thirteenfold increase from 2011 to 2015 in spending on patients with opioid dependence or abuse diagnoses, Medicaid has seen a comparable increase in its expenditures on these treatments. In recent years, spending from Medicaid on opioid addiction treatment has risen dramatically. From 2011 to 2016, Medicaid spending on just two medications used to treat opioid addiction, buprenorphine and naltrexone, rose 136% on average nationwide, with spending in some states increasing as much as 400%. Furthermore, Medicaid is a major program when it comes to individual patients having access to drug treatment programs. In 2014, Medicaid paid for a quarter of drug treatment programs. Although activists have managed to fend off the continued attacks by Republican lawmakers that would throw out the ACA and put in place block grants and spending caps that drastically decrease Medicaid funding, if such an attempt eventually succeeds, millions of Americans may lose access to addiction treatment.
CVS’s new policy limiting access to opioid painkillers is a misguided attempt to reduce illicit access to painkillers by punishing patients who have, and need, legitimate access.
In practice, CVS’s new regulations on opioids ignore the real problems with opioid addiction and foist the responsibility for the epidemic on patients in pain. Andi, who is all too familiar with the controversy surrounding access to opioid painkiller, sums it up: “all doctors who prescribe medicine have a responsibility to prescribe responsibly. No patient should be made to feel that he or she is somehow dangerous, or irresponsible, or needs to be closely watched solely because there is ‘an epidemic’ out there.”