In March, 2016, the Centers for Disease Control (CDC) released guidelines for prescribing opioids for chronic pain. The guidelines included recommendations on when to use opioids (rarely), when to discontinue them, dosage levels (including recommended maximum dosage) and suggestions for monitoring. The guidelines were billed as voluntary. The CDC says they don’t hold the force of law or regulation. The guidelines were a response to a serious and growing problem: millions of pain patients who were prescribed opioids became addicted to them and hundreds of thousands have died as a result.
Since the guidelines were released, reports of pain patients being abruptly cut off of their medication or having their medication sharply and abruptly reduced are rampant. Usually, patients report that no alternative pain treatment has been offered. Patients report devastating consequences. Besides significant increases in their pain levels, patients often report going from being functional adults able to work and fulfill their responsibilities to being completely nonfunctional. In most cases, patients reported they were using opioids long term, sometimes for decades, with no evidence of addiction or increases in dose. In addition, many patients who moved to other parts of the country reported being unable to find a doctor who would treat them, or, if they found one, who would give them their usual dosage of medication.
Why would a doctor do this to a patient? Aren’t doctors supposed to “first do no harm”? Here are a few reasons.
Doctors have been criminally prosecuted in the past for prescribing opioids, even in the absence of any evidence of criminal intent, while prescribing in ways that were considered “standard of care’.
When the opioid epidemic first became apparent, it became obvious that many patients were becoming addicted to medications the pharmaceutical companies had claimed were not addictive. The authorities needed someone to blame rather than the drug companies, so they started focusing on doctors. There were a few unscrupulous ones who had set up “pill mills”, practices where people without any legitimate medical need for the drugs and without the requirement of a medical examination, could obtain prescriptions for opioids for the right price. Apparently there weren’t enough of those to make a big enough impression, so the Drug Enforcement Agency (DEA) started targeting other physicians.
Some doctors have been tried as drug kingpins and dealers and prosecuted for manslaughter when their patients misused the drugs they were prescribed and died of an overdose. These physicians, when convicted, are subject to the same draconian mandatory drug sentencing laws as violent individuals dealing illegal drugs. Under the Comprehensive Crime Control Act of 1984, the assets of suspected drug dealers, including MDs who treat pain with opioids, can be seized without hearings or trial; consequently, they are stripped of the assets they require to defend themselves.
In his 2008 book, The Criminalization of Medicine: America’s War on Doctors, Ronald Libby recounts the stories of several physicians prosecuted for overprescribing, including Dr. James Graves, a family doctor in Pace, Florida, who specialized in pain management.
Graves was tried and convicted in 2002 for racketeering, drug trafficking, and manslaughter and received a sentence of 62 years in prison. Graves was the first doctor to be convicted of manslaughter as a result of prescribing painkillers to patients who died of an overdose. During his career, Graves worked on numerous occasions as a medical missionary in Ghana, Haiti, and India. He also served 17 years as a navy flight surgeon before being honorably discharged in 1994. After his discharge, Graves worked a series of temporary jobs before opening his own private practice in 1998. Graves was reported to the authorities for allegedly dealing drugs by a former employer, a chiropractor, who believed that Graves was violating a non-compete clause in his employment contract. As a result of this complaint, the government arrested Graves and closed down his practice in 2000. He had no income or savings and was forced to cash in a life insurance policy to post collateral for his bail bond. The court declared him indigent, and he was represented by public defenders. Prosecutors persuaded drug addicts facing extended jail time to entrap Graves and testify against him in exchange for more lenient sentences. Two doctors testifying for the defense stated that Graves’s treatment of the patients who died was within the standard of care of medical practice in the United States and was for a legitimate medical purpose. None of the prosecution witnesses stated that Graves’s treatment of the patients was wanton, reckless, grossly incompetent, or purposely homicidal. The prosecution failed to prove that he was medically negligent toward these patients, or even that he was the cause of his patients’ deaths. Some of the deceased patients named in the trial were not even his patients or had died long after he stopped treating them. It was never proven that he accepted any money in return for drugs. Despite all of this, Graves was still convicted and sentenced to what amounts to life in prison.
Grave’s case became a precedent for prosecutors to use against pain doctors across the country. Other physicians have lost their licenses under similar scrutiny. Some have prevailed against charges, but only after spending sometimes hundreds of thousands of dollars in their defense.
Cases such as Graves’s allow the government to assert that it is doing something to address the problem of prescription drug addiction while allowing these highly addictive, very dangerous—but very profitable—drugs to stay on the market. These cases have had a chilling effect on many medical practices.
With the promulgation of the CDC opioid prescribing guidelines, physicians see themselves as in even greater legal risk. Guidelines from the federal government, or even from medical specialty groups, are generally treated as “standards of care” and physicians who don’t adhere to them are at greater legal risk if a complaint is filed.
Many physicians no longer make the policy decisions about their practices.
Because of the pressures put on physicians over the last few decades by insurance companies, many physicians in self-defense have joined large practice groups or sold their practices to hospitals. In these circumstances, even if physicians want to be more flexible and treat their patients with more compassion, they are often being told how to treat their patients by practice managers or the legal counsel’s office of the hospital. These individuals are usually even more risk-averse than the doctors themselves and make these decisions without the benefit of seeing their impact on patients.
Physicians have not been trained in how to appropriately withdraw patients from medications.
Physicians mainly get their education in how to prescribe drugs from pharmaceutical company drug representatives or from “thought leaders”, respected physicians hired by the drug companies to deliver scripted talks about the benefits of the drugs. Pharmaceutical companies like having lifelong customers because it enhances their bottom line, so they rarely discuss how to safely withdraw patients from drugs. If they do offer guidance, a faster than optimum dose reduction schedule is often recommended. When that’s done, patients develop withdrawal symptoms that are only relieved by going back on the drug, “proving” they needed the drug.
Physicians are rarely knowledgeable about alternative pain treatments, and those treatments are rarely accessible to patients.
The CDC guidelines recommend that patients be provided with nonpharmacological therapies prior to a gradual taper from opioids. Physicians have limited knowledge of these treatments. Even when they are knowledgeable about alternative pain treatments, insurance restrictions mean there is little to no coverage and most pain patients can’t afford them. In many cases, many of these services are not available in many communities.
What needs to be done.
The DEA’s reign of terror over physicians needs to end. Physicians need more education about addiction and safely withdrawing patients from opioids. Patients who are comfortable with their long term opioid use who show no evidence of addiction or dose escalation should be offered alternative treatments but allowed to stay the course. Alternative pain treatments need to be adequately covered by insurance companies and all physicians and patients need to be educated about them.
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