Washington State Pain Crisis — a Bellwether?

Even before new rules governing opioid prescribing in Washington state go into effect next month, in January 2012, access to adequate pain care is becoming scarce in the state. And, there are signs that this could be a harbinger of trouble and bad times ahead for persons with pain in other parts of the United States.

Aggressive new laws for the management of chronic noncancer pain, intended to curb rising opioid overdose deaths in Washington state, have been discussed in previous UPDATES [here] and [here]. Last September 2011 — concerned about reports that access to any type of pain care was becoming more difficult for the 1.7 million persons in the state with chronic pain conditions — the American Pain Foundation (APF) conducted a special survey to evaluate what seemed to be a mushrooming crisis.

APF staff contacted by telephone 108 statewide community health clinics. These facilities provide primary healthcare services to patients who are covered by Medicaid and many typically underserved populations, including, in some cases, persons who are uninsured.

Surprisingly, 70% of the clinics contacted said that they do not treat any patients with chronic pain, and most of those clinics have no referral process to send such patients elsewhere for treatment. Another 16% of clinics said they will treat patients with chronic pain; however, 10% will not provide opioid analgesics for pain and 6% would accept patients with chronic pain only under certain conditions, such as: a) having an existing treatment plan from a pain specialist, b) willing to discontinue opioid therapy, or c) have a specific type of insurance. The remaining 14% of contacted clinics simply stated that they were still willing to see patients with chronic pain; although, some commented that their policies in this regard may change.

The brief APF survey report is available [here]. As the report authors ask, “Where are people with pain of little financial means expected to receive appropriate, effective, and safe pain care?” Based on this new information, APF is asking Washington state stakeholders and legislators to re-evaluate the growing gap in pain care and to work with others to develop reasonable solutions that address this crisis.

COMMENTARY: Access to pain care and relief of suffering should be a human right, and the situation in Washington state should be of concern and rather frightening to everyone, with or without chronic pain. Can anyone imagine patients with any other chronic and potentially life-threatening medical condition — for instance, diabetes or heart disease — being turned away from healthcare facilities? Or, if accepted for treatment, would those patients be denied medication that is effective, essentially safe when properly used, and considered a standard of care in many cases?

Actions to curtail perceived problems with opioid analgesics in Washington state could be directly threatening the welfare of countless of its residents. And, the resulting pain care crisis in this state could be a bellwether of what is coming in many other parts of America, and probably in other countries as well. (Appropriately, the original definition of “bellwether” is a sheep, usually wearing a bell around its neck, that leads the rest of the flock.)

Furthermore, the fallout, or unintended consequences of this, could be very ugly. Here are some warning bells that have been ringing in recent news reports:

• According to an Associated Press report [reprinted here] crackdowns on Florida’s “pill mills” — notorious for the reckless distribution of prescription opioids — have sent both crooks and legitimate patients flocking to Internet pharmacies to purchase opioid pain relievers. Although it is illegal, offshore operations stretching from the Ukraine to China welcome customers without prescriptions, and their business in booming. Will it be only a matter of time before these mail-order drugs, of questionable quality and content, spur a surge in overdoses and deaths?
  
  
• Another recent Associated Press report [reprinted here] comments that there has been a sharp rise in heroin abuse in the state of Iowa. This came after a surge some years ago in prescription drug misuse, followed by a crackdown on those medications in the state, and then a subsequent reappearance of cheaper and more potent heroin. Authorities are concerned that unpredictable strength and purity levels of heroin are playing a significant role in escalating drug overdoses and deaths. This same problem had started appearing some time ago in Washington state, as reported in an UPDATE last March [here].
  
  Will increasingly limited access to prescription opioids result in a shift of the problems to heroin, with all of its morbidity and mortality? Might some of the newest initiates to heroin include patients with chronic pain who feel they have no other recourse?
  
  
• On December 1, 2011, it was reported that the large retail drug chain, CVS/pharmacy, started refusing to fill prescriptions for opioid analgesics in Florida written by physicians that the firm deemed to be “high prescribers” [news item here]. Criteria for landing on the disqualification list were not entirely clear, and a CVS representative would only comment that the list of prescribers was developed with help from the federal Drug Enforcement Agency (DEA). The firm expressed concern about escalating drug overdoses in the state and is determined to “prevent drug abuse and keep controlled substances out of the wrong hands,” a CVS spokesperson stated. The question is, will this unprecedented action also end up keeping needed analgesics out of the hands of legitimate patients?
  
  
• Finally, in what might be viewed as somewhat ironic, Washington state is one of only two states that have assisted-suicide laws. American Medical News reported [here] that 51 patients in Washington died in 2010 after taking life-ending medication prescribed by physicians under the first full year of the state’s “aid-in-dying” law. This was a 42% rise from 36 physician-aided deaths during most of 2009. There has been a steady increase in numbers of participating physicians and a continuation of patients who want to use the law, although the percentage of all deaths in the state under this law has been small.
  
  The irony here is that the state seems to have compassion for hopelessly ill persons, legislating an option for death with dignity, yet appears to have a rather cavalier outlook when it comes to the suffering and needs of persons with chronic pain. Will assisted suicide requests rise as pain sufferers in the state increasingly foresee no other options for relief?

The above are but several recent examples from news reports. Those persons who would divert and/or misuse prescription opioids will find other ways of supporting their aberrant and/or illegal substance-using behaviors. Solutions to these problems that, at the same time, deny access to vital medications by persons with pain are unduly punitive and largely ineffective.

Attempts to safeguard public health and protect society from the misuse of potentially harmful but legal opioid analgesics should not end up threatening the health and well-being of large numbers of persons who rely on those same medications to remain functional and enjoy a reasonable quality of life. There are challenging obstacles to be overcome, but legislators, law enforcers, and healthcare providers should keep in mind that they or a loved one could very well become the next victim of chronic noncancer pain — how would they want to be treated?