Full Court Press on Opioid Pain Medication

By Pat Anson, Editor

A full court press is a defensive basketball tactic in which a team applies relentless pressure on an opponent the entire length of the court.

This past week felt like a full court press against prescription opioids, with government regulators, politicians, and even economists weighing in on the opioid crisis – almost all of them pointing a finger of blame at pain medication.

Where to begin?

On Tuesday, sixteen U.S. senators wrote a letter to the head of the Drug Enforcement Administration asking the agency to make further cuts in the production of hydrocodone, oxycodone and other opioid pain medications in 2018. The DEA has already reduced the supply of Schedule II opioids by 25 percent or more in 2017.

The letter, which was signed by 15 Democrats and one independent -- many from states where deaths from heroin and illicit fentanyl have eclipsed those from painkillers -- doesn’t even mention the role of illegal drugs in the overdose crisis, pinning the blame solely on pain medication.

“In order to effectively combat this raging crisis, stakeholders -- especially our federal oversight agencies -- must use every tool available to prevent the flood of addictive narcotic painkillers onto the market that can result in misuse, abuse, and diversion,” said the letter.

On Thursday, the Food and Drug Administration signaled that it was prepared to use some of those tools. An FDA funded report by the National Academies of Sciences, Engineering, and Medicine called for a national campaign to combat the opioid crisis, including more aggressive regulation of opioid medications and a “cultural change” in the way they are prescribed.

At the same time, the report warned that the illicit and prescription drug markets are "intertwined" and that "regulatory efforts designed to reduce harms associated with the use of prescription opioids may be contributing to
increased heroin use."

FDA commissioner Scott Gottlieb, MD, welcomed the report with a lengthy statement that completely ignored the role of heroin and illicit fentanyl in the opioid crisis.

“I’ve asked my FDA colleagues to take a fresh look at some key features of the agency’s regulation of opioids, including provider education, benefit-risk assessment in the pre- and post-market setting, and steps we can take to reduce overall exposure to these drugs,” Gottlieb said.

‘Extreme Amount’ of Opioids Prescribed

Also on Thursday, the Department of Health and Human Services’ Office of Inspector General (OIG) published a widely cited and inflammatory report claiming that over half a million Medicare beneficiaries were receiving high doses of prescription opioids.  The estimate is based on the premise that a daily morphine equivalent dose (MME) greater than 120 mg is a “high amount” and a dose of 240 mg or more is an “extreme amount.”

Those would be high doses for most pain patients, but not for Rick Martin, a retired Nevada pharmacist disabled by severe chronic back pain. Martin says he needs up to 300 mg (MME) of opioids daily just to be able to stand and walk for any length of time.

“I am really really incensed about the OIG using the word ‘extreme’ in defining people who take greater than 240 MME/day.  This is shouting fire in the movie theater,” Martin wrote in an email to PNN. “Patients who have long term persistent pain are where they are due to the medical community failing to correctly diagnose and treat what is causing the pain in the first place.  

“So in the OIG's eyes, not only am I a chronic pain patient on long term monitored opioid prescription medications, I am now considered EXTREME ! What a degrading moniker that is. In 6 months, I'll be called an EXTREME OPIOID ABUSER.  That's the next level to come down the pike.”

Like the senators’ letter to the DEA and the FDA study, the OIG report virtually ignores the illegal drug trade, instead blaming patients and providers for the opioid crisis. The report estimates that 400 doctors have “questionable” prescribing practices and 22,000 Medicare beneficiaries are doctor shopping.

“The extreme use of opioids and apparent doctor shopping described in this study put beneficiaries at risk and may indicate that opioids are being prescribed for medically unnecessary purposes and then diverted for resale or recreational use. It may also indicate that beneficiaries are receiving poorly coordinated care,” the report says.

On Thursday, the Justice Department also announced a nationwide crackdown on health insurance fraud and the illegal distribution of prescription opioids. Over 400 people were arrested nationwide, including many doctors, nurses and healthcare providers.

"While today is a historic day, the Department's work is not finished. In fact, it is just beginning. We will continue to find, arrest, prosecute, convict, and incarcerate fraudsters and drug dealers wherever they are,” warned Attorney General Jeff Sessions.

Opioid Crisis Affecting Job Market

Surprisingly, it was left to economists to take a more nuanced view of the opioid crisis – noting there are many other factors involved besides pain medication

Federal Reserve chair Janet Yellen told the Senate Banking Committee that economic despair was one reason that the labor force participation rate remains stubbornly low, despite declines in the unemployment rate.

“Unfortunately this is likely tied to the opioid crisis, the problems that many communities have. We’ve seen an increase in death rates due to despair, suicide, drugs in these communities,” Yellen said, adding that the United States is "the only advanced nation that I know of where in these communities we're actually, especially among less-educated men, seeing an increase in death rates partly reflecting opioid use."

Yellen was reacting in part to a Goldman Sachs report  which blamed opioids of all kinds – both legal and illegal – for keeping millions of Americans unemployed during their prime working years.

“Use of both legal prescription pain relievers and illegal drugs is part of the story of declining prime-age participation, especially for men,” economist David Mericle wrote in a research note that attributed a spike in overdoses to “heroin and illicit fentanyl users, most of whom previously used prescription opioids but switched to these cheaper, more accessible drugs.”

Trump Opioid Commission Delays Report

Curiously silent during a week full of opioid news was the White House Office of National Drug Control Policy, which quietly postponed the second meeting of President Trump’s Opioid Commission.  A notice published in the Federal Register Friday said the commission’s second meeting has been postponed until July 31, the second time the meeting has been rescheduled.  No explanation for the delay was given.

Also delayed was the commission’s interim report on how the federal government should address the opioid crisis, which is now over a month overdue.

At the commission’s first meeting in June, testimony was taken only from government officials and addiction treatment advocates. Pain management experts and patient advocates were not asked to appear, nor are they represented on the commission itself.