Gov. Chris Christie framed his pledge to limit opioid prescriptions to a five-day supply, one of several new concepts he outlined in his State of the State speech Tuesday, as a way to curb the availability of these highly addictive medications and help “prevent addiction before it starts.”
But advocates for those prescribing these pills are adamant that the change would do more harm than good. Limiting prescriptions could endanger patients with legitimate pain and possibly drive them to harder drugs, like heroin, they said. Such mandates could also discourage doctors from becoming licensed to prescribe such drugs, further limiting the options for desperate patients.
On Tuesday, Christie labeled as “excessive” the current policy allowing doctors, dentists, and other licensed providers to write a 30-day prescription for opioid-based drugs to address complaints ranging from a broken arm to chronic pain to wisdom tooth pain. Too often these medications disappear from the patient’s medicine cabinet and end up being used illegally. The majority of heroin users started out on pills, Christie said, before switching over to the cheaper, more powerful street drug.
The Medical Society of New Jersey, the lobbying force for the state’s doctors, has regularly opposed prescription limits as an intrusion in the practice of medicine. Patients are not generally the ones becoming addicted, it said, and they shouldn’t be punished in an effort to better control the larger addiction epidemic.
“We need to be very careful about how all this attention to the overuse of opioids has stigmatized the cancer patient … has stigmatized all patients with pain,” said Dr. Kathleen Foley of Memorial Sloan Kettering Cancer Care at a conference on pain and addiction held at the Princeton University Center for Health and Wellbeing, in December.
Foley said Sloan Kettering doctors already have trouble getting pain prescriptions filled, or refilled, for some patients and, “these complicated regulations are interfering with daily lives.”
The issue is one of several Christie outlined in his annual speech that are likely to generate political heat and policy debate; his call for an insurance mandate requiring coverage for six months of residential or outpatient drug treatment has also sparked spirited discussion among industry leaders, regulators, and other stakeholders. The governor also proposed plans to open up new treatment beds, especially for older teens, and expand access to sober housing and job opportunities.
While the overall goal the governor outlined in the speech — reducing the impact of addiction — was generally well received, observers have started to question how some of the specifics will be implemented and, in some cases, if they are overly broad.
Many noted that several of the concepts Christie mentioned have already been considered, or adopted, by the state Legislature — including in a bill (S-2035), adopted by the Senate in June that would limit doctors to a seven-day prescription for opiates. The measure has yet to be posted in the Assembly health committee, chaired by Assemblyman Herb Conaway (D-Gloucester), a physician who has made clear his opposition to mandates, including mandates on prescription.
At the pain and addiction conference at Princeton, sponsored by the Nicholson Foundation, Dr. Jane Ballantyne, with the University of Washington Medical School, explained that dependence and addiction are not the same thing; they may share physical characteristics, but they involve very different behaviors, with addicts often becoming socially withdrawn, disruptive and out of control. That said, Ballantyne added, “there’s no bright line between dependence and addiction; most of the patients we see fall somewhere in the middle of the spectrum.”
For those who are dependent, a life without medication can mean pain — and potential physical withdrawal. And some fear that, if they don’t have pills, the overpowering need for relief will drive these desperate patients to seek out street drugs like heroin to get some immediate relief.
Advocates for physicians point to data from the federal Centers for Disease Control and Prevention, released in December, that shows heroin-related deaths shot up more than three-fold between 2010 and 2014, suggesting it reflects in part the impact of regulations designed to limit access to prescription opioids.
“Heroin abuse increases as prescription medications are limited,” said Mishael Azam, an executive and legislative affairs manager with the Medical Society.
Azam said former Attorney General Jeff Chiesa echoed that point several years ago when the state moved to create a prescription monitoring database designed to help doctors weed out patients with addictions, and quoted him as saying that “high levels of prescribing and dispensing of controlled drugs are not necessarily indicators of illegal activity or drug abuse.”
At the Princeton pain conference, Grant Baldwin, a CDC representative, said that while four out of five heroin addicts may have started with prescription drugs, new studies show the majority of legally prescribed opiate users do not end up on street drugs. That said, he added: “I think the solution to the problem is both on the supply side and the demand side.”
Another concern is the long-term impact of these mandates on physicians and their interest in prescribing opiates and other pain medications, Azam said. In New Jersey, this requires a separate license — and another set of fees — in addition to their standard medical license. She pointed to data compiled for a Boston Globe article published earlier this month that suggested more than half of doctors nationwide are curtailing their opiate prescription practice and one in ten are getting out of the business. More than one-third of the 3,000 physicians who were surveyed said these changes have hurt patients with pain.