Part 1 in this series covered how bureaucratic regulations and laws based on subpar research led to unfair restrictions on legal narcotics, resulting in fewer doctors willing to prescribe. Names have been changed to protect identities
Todd W., 72, a retired boilermaker from Frenchtown, Mont., looks back on his career with pride, saying, “We built Colstrip,” and other dams and power plants. He suffered an industrial accident that nearly tore off one arm and one leg. Using a low maintenance dose of Dilaudid, he had been able to take care of his home, even cutting wood for heat.
Last winter, his doctor’s office requested that Todd sign a paper they said was meant to protect his doctor if his drugs were stolen. Trustingly, he signed without reading the paper.
Several months later, his doctor sent a letter saying she would no longer prescribe controlled substances, because he had supposedly breached the controlled substance contract.
His error? He filled a prescription at a different pharmacy than listed on the contract and supposedly filled it too early, even though he said the prescription was dated that same day.
When he tried to find a new doctor, two walk-in urgent care facilities turned him down, claiming they weren’t taking new patients. Pharmacies will not fill his prescriptions.
Todd claims he was blacklisted and turned to “other things” to control his pain.
Many doctors now require patients to sign contracts regarding controlled substances. No standardized contracts exist. Doctors may adopt forms inappropriate for primary care, instead using contracts from pain clinics focused on addiction and abuse.
Although such contracts are not necessarily based on rules or laws, they have been used to restrict pain control, as in Todd’s case.
Even though all pharmacies must check the drug registry database before dispensing controlled substances, most contracts require the patient to use only one pharmacy. That restriction penalizes low-income patients who often shop various suppliers, looking for the least expensive drug price. If they refill prescriptions from a different, cheaper provider, they are reported and may be blocked from obtaining needed drugs.
Many seniors can barely afford their medication, yet physicians are under pressure to enforce unfair contracts for fear of losing their licenses.
When legitimate, legal avenues are cut off, what are seniors supposed to do?
Fanning Patient Fear
Ruby S., 91, broke her hip and was prescribed a Schedule II narcotic, which she tolerated well while hospitalized. When transferred to a rehab facility, however, she was taken off hydrocodone with Tylenol and instead given more than 6 grams of Tylenol for pain control. Because of her age and gender, such high doses of Tylenol were more dangerous for her than low doses of hydrocodone with Tylenol.
At home, Ruby resumed walking for exercise but suffered pain. Because of media reports about opioid dangers, she was afraid of becoming addicted.
On her own, she took large doses of nonsteroidal anti-inflammatory drugs (NSAIDs), putting herself at risk for kidney and/or stomach damage.
Her doctor became alarmed and had to convince Ruby that, given her age and health, low-dose hydrocodone with Tylenol was far safer than over-the-counter (OTC) medications.
Because of 2016 CDC guidelines, Worker’s Compensation forced Angela H., 68, to taper off her narcotics she had taken for 30 years due to a work-related injury. Drugs enabled her to get through her day.
Angela endured three months of pain so intense she could hardly get out of bed. When she finally visited her physician, the doctor was shocked by her appearance—sunken eyes, pale, and barely able to walk.
Worker’s Comp had required Angela’s 90 days of unnecessary suffering to demonstrate that she needed the narcotic, even though she’d taken the same dose without problem for 30 years.
Myths and Facts About the Opioid Crisis
According to Pain Medicine News, prescription opioid use peaked in 2011 and has since declined, leading experts to wonder if new laws and regulations are out of step with current conditions.
To further complicate matters, the recommendations keep changing, often contradicting earlier versions.
According to a December, 2018 article in Modern Healthcare, the U.S. Food and Drug Administration issued a safety warning in 2016 for providers and patients against combining opioids and benzodiazepines (drugs like Valium, Xanax, Ativan, etc.). “But in an updated statement the next year, the agency switched course and told providers not to withhold opioid use disorder treatments from patients using central nervous system depressants because the harms caused by not treating opioid addiction outweighed the risks.”
In March, 2019, a group of pain experts said a “large-scale humanitarian issue” resulted from policies that forced patients to taper off too quickly or to stop narcotics altogether. Seniors went into withdrawal, adding more pain on top of what they were already suffering.
According to Dr. Bukacek, OTC pain medications can be more dangerous than low-dose narcotics, especially to seniors. Plus, she says, alternative prescriptions like gabapentin often cause intolerable side effects and have addictive potential themselves.
When forced to abide by one-size-fits-all regulations, doctors can no longer take into account the individual patient’s unique history and condition when prescribing narcotics.
The great majority of seniors and veterans taking opioids are not drug abusers. They use narcotics responsibly under careful supervision by a physician. Pain control allows them to work, care for their homes, themselves, and family, giving them better quality of life.
Without safe, effective alternatives, what are seniors and vets in pain supposed to do?
Apples to Oranges
A November, 2018 report from the CDC showed that, despite a reduction in prescriptions written for narcotics, the drug overdose rate continues to soar because of illicit opioid fentanyl and related drugs. Their 2016 recommendations may have done more harm than good.
Scary figures about illegal drug use, like the 500-percent increase in meth use and the 1557-percent increase in heroin, are often lumped with data about legal narcotic prescriptions, misleading the public.
Illicit substances combined with fentanyl and other narcotics are not prescribed by doctors. They are sold illegally, not by pharmacies. Comparing street drugs with legally obtained prescriptions is comparing apples to oranges.
Among fraudulently obtained prescription drugs, the majority stem from falsified or forged physician signatures, or stolen or diverted drugs. These acts are crimes, not the result of legitimate prescribing.
Attorneys General of many states admit that narcotics prescribed by doctors are a miniscule part of the problem. The DEA record of “Cases Against Doctors” lists only one Montana doctor and one Idaho doctor who have been convicted on controlled substance violations.
Yet the government solution is to regulate or control physician prescribing. As a result, law-abiding seniors with legitimate medical needs for pain control are often treated as if they are addicts and criminals, and so are the doctors writing prescriptions for them.
Fear of Prescribing Needed Opiates
Phyllis J., 67, fell out of bed and fractured her arm. Because she lives alone and could not drive, she suffered at home for more than a day before she was able to get to the hospital.
There, the ER doctor X-rayed her broken arm, put it in a sling, and told her to follow up with an orthopedic specialist. Phyllis was already on a low dose of Tylenol with codeine for headaches, so the ER doctor felt that was adequate and sent her home.
The next day, she could no longer stand the excruciating pain and called her primary care physician. Her compassionate doctor recognized she needed a stronger drug for relief and prescribed hydrocodone with Tylenol, and arranged for home delivery, because Phyllis could not drive.
Under the circumstances, hydrocodone with Tylenol should have been given at the ER, but regulations make medical providers overly cautious of prescribing narcotics, even when they are desperately needed and completely justifiable. Phyllis suffered unnecessarily before she received adequate pain control.
Part 3 of this series will cover unfair burdens to refill prescriptions, and how seniors can fight back. ISI
Ann Bukacek, MD, practices internal medicine in Kalispell and was awarded the 2019 American College of Physicians Laureate for Montana. She serves on the Flathead City-County Board of Health. Debbie Burke lives in Kalispell and writes mystery/suspense novels as well as articles. Her recent thriller, Stalking Midas, addresses elder fraud. debbieburkewriter.com