Doctors bristle at push for opioid prescription limits


An increasing number of states and entities in the health industry are putting curbs on the amount of opioids that doctors can prescribe, a controversial move aimed at combating the opioid crisis.

These limits have garnered support from various stakeholders and are now being considered in Congress, with a bipartisan group of senators proposing to set a cap on first-time prescriptions for acute pain.

{mosads}But the opioid limits have sparked opposition from the American Medical Association (AMA), the powerful group of physicians. It warns that the opioid rules are arbitrary and inhibit a doctor’s ability to care for their patients on an individual basis.

The AMA “supports and encourages judicious prescribing of opioids,” said Dr. Patrice Harris, chairwoman of the association’s opioid task force. But the AMA has “grave concerns” about limits on both dosage and supply.

“Pain is a complex, biopsychosocial phenomenon, and individuals experience pain in different ways,” Harris said. “The AMA believes that decisions around dosages needs to be left between the patient and the physician.”

Supporters of the opioid limits argue the measures are important to curb overprescribing, stem the volume of painkillers that could be diverted for illicit use and decrease a patient’s potential to develop an addiction.

Congress, the administration and state governments are all searching for ways to address the opioid epidemic, which is killing thousands of people per year and has shown no signs of slowing down.

But some doctors are wary of strict mandates, fearing they will get in the way of proper patient treatment.

“Most people think, and I agree, that excess prescribing of opioids was at least one major contributor to today’s tragedy. And so the instinct that we need to continue a course correction of a serious nature is well placed,” said Dr. Stefan Kertesz, professor of medicine at the University of Alabama Birmingham School of Medicine.

“The question is, when is that course correction best enforced as a matter of governmental mandates, and when is that course correction best advanced through a combination of state-based educational and regulatory initiatives that might fall short of hard and fast legislation,” Kertesz said.

Momentum has built behind imposing limits on opioid prescriptions.

In early 2016, Massachusetts became the first state to establish such a restriction, setting a seven-day supply limit for first-time opioid prescriptions. By the end of the year, seven states had passed some type of limit.

As of early April 2018, 28 states have an opioid prescribing limit, guidance or requirement on the books, according to the National Conference of State Legislatures.

Many of the laws cap the supply of first-time opioid prescriptions, such as three or seven days. In a few instances, states have moved to set limits on opioid dosage, placing restrictions on milligrams of morphine per day.

“I think that these policies are an important part of a comprehensive solution to address the opioid crisis,” said Dr. Caleb Alexander, the co-director of the Johns Hopkins Center for Drug Safety and Effectiveness.

But Alexander cautioned that “no single policy is a magic bullet” and that prescription limits should be accompanied with other measures, such as improving care for those in pain and treating those with an opioid addiction.

While Congress hasn’t acted to create opioid restrictions, the Centers for Disease Control and Prevention (CDC) did issue nonbinding guidelines to doctors in 2016. When opioids are used for acute pain, the CDC says, a prescription of three days or less “will often be sufficient” and “more than seven days will rarely be needed.”

Restrictions on the supply of opioids have some powerful backers.

In September, the Pharmaceutical Research and Manufacturers of America announced its support for limiting a patient’s supply of opioids to seven days for first-time acute pain treatment. The lobby group also supports a 30-day supply limit on opioids for chronic pain treatment.

Some private insurers, pharmacy benefit managers and pharmacies have already imposed some limits, such as pharmacy benefit managers CVS Caremark and Cigna.

Late last month, the American Dental Association (ADA) said it wants to put a seven-day limit on dentists’ opioid prescriptions for acute pain. The group’s president, Dr. Joseph Crowley, said that most of the time, dentists’ patients aren’t facing long-term, chronic pain — and that often over-the-counter products are “as effective or more effective” than opioids to solve acute pain.

It makes sense that the ADA’s and AMA’s guidelines are different, Crowley said, because dentists and doctors deal with different patient needs.

Dr. Andrew Kolodny questioned the effectiveness of limits on prescriptions, noting that seven and even three-day prescriptions still come with a lot of pills.

“Lawmakers are passing these bills because they all know a story about someone who got 30 pills when they only needed one or two, and so they’re passing these laws,” said Kolodny, the co-director of the Opioid Policy Research Collaborative at Brandeis University.

“But passing a limit based on duration of use — especially seven-day duration of use — is not going to get at that,” he said,

Rather than limiting the supply of opioids, Kolodny said lawmakers should consider measures like requiring a patient to sign a consent form saying they’ve been warned of the risks associated with opioids.

Back on Capitol Hill, lawmakers are considering several opioid measures.

Senate Health Committee leaders released a bipartisan discussion draft last week that asks the Health and Human Services secretary to issue a report on laws regulating the length, quantity and dosage of opioid prescriptions.

At least one bipartisan group of eight lawmakers proposed a three-day limit on first-time prescriptions for acute pain. This provision was included in a follow-up bill to the Comprehensive Addiction and Recovery Act, dubbed “CARA 2.0,” which was introduced in late February.

The measure has received pushback, but the senators aren’t backing down.

Sen. Rob Portman (R-Ohio) — a chief sponsor of the bill — said it includes carve outs, such as exceptions for those with chronic pain and cancer, meant to address concerns of medical providers.

“After three days, someone can go back to the doctor and renew the prescription if it’s legitimate, but there should be a process there to do that,” Portman told The Hill.

“I just am tired of talking to families who have gone through this, whose kids — or not only kids, sometimes it’s adults who are overprescribed — became addicted and their lives were forever changed because of it,” he said.

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