The Opioid Guidelines

As long as we're on the topic of painkillers, I came across a separate article recently in which I learned that Washington state (where I live) has historically been considered "opiophobic." I'm not surprised by this; my wife has had run-ins with substitute general practitioners who haven't even bothered to open her chart and have just flat out denied filling her Vicodin prescriptions, despite a well-documented history that demonstrates why she needs it and a life path that demonstrates she's not just yanking a doctor's chain to get meds. But this recent article posits that this is just another facet of the war on drugs, the increasing tendency to inappropriately judge people based on their prescription drug use:

When Brenda Sutherland stepped up to renew her prescription for her pain medications at a local drug store, she said the pharmacist sneered and made comments about “all of her drugs.”

“He immediately copped an attitude,” the Puyallup resident said. “He started asking me a bunch of personal questions about my medical history. His job is just to fill prescriptions.”

He didn’t lower his voice and made his opinion known to all who were in earshot....

Sutherland later called the pharmacy to complain and received an apology. But she had already been publicly humiliated.

“He had no right to stand there in front of other people and discuss my medical problems,” she said. “He had the attitude that I was drug seeking.”

New prescription guidelines have created a rather Quixotic situation in which doctors must endure arbitrary engagement with a dwindling class of pain specialists in order to prescribe; some doctors are finding it's not worth the red tape.

[John Loeser, Professor of Neurological Surgery and Anesthesiology at the University of Washington,] said the Opioid Guidelines that have stirred up such a huge furor are actually very benign.

“They don’t say that patients can’t have pain medications, they don’t say that,” he said. “They say that if a patient is being given more than 120 milligrams of morphine or its equivalent then a consultation with a pain specialist is required.”

The problem is there is a huge shortage of pain specialists, Loeser said.

“There aren’t enough pain specialists to begin to meet this mandate. It usually requires residency of a year in an accredited pain fellowship program.”

The problem with a relatively arbitrary guideline like 120 milligrams is the widely differing responses to that dose, based on a wide variety of possible causes for prescribing the drug in the first place:

Loeser said there is inconclusive data to support the effectiveness of high amounts of pain medication.

“I see lots of people who come in to get their prescriptions of 20 to 60 milligrams of morphine, or the equivalent, every day and they tell me their pain is under control,” he said. “Then I see people taking in between 300 and 3,000 milligrams per day and I’ve never seen one tell me they’re pain-free. Underlying this is the recognition that not all pain problems respond to narcotics, so the prescriptions get pushed up and up. We are forced to make decisions in the absence of good knowledge.”

Of course, making decisions in the absence of good knowledge is a staple of government, but still. At a time when a prescription med becomes a street drug the moment you hand it to someone whose name isn't on the label, fear of persecution for "diversion" has never been more prevalent. So what if those suffering from chronic pain get embarrassed publicly by their pharmacists?