To the Editor:
As a pain physician with experience treating chronic pain patients over the past 30 years—initially as medical director of the Boston Pain Center, subsequently the Presbyterian Hospital Pain Center and currently Carolina Pain Associates—I need to share my thoughts on the current health care crisis as it affects patients who have acute and chronic pain.
Across the country but especially in the South, with Broward County in Florida one of the earliest areas to be in crisis, pain patients are increasingly unable to get their pain medication prescriptions filled. This is especially true for controlled substances and most problematic when those substances are opioid analgesics. Multiple colleagues have called me from Broward County to tell me stories of patients with legitimate chronic pain problems, who had been appropriately using their pain medications for years, and were now going from pharmacy to pharmacy to find their medications. Especially in the past six months, many pharmacies are not receiving up to 75% of the opioid analgesics that they used to receive. Some community pharmacies have notified patients that by the end of the first week, the pharmacy’s monthly allotment was gone. Pharmacist Steve, an experienced pharmacist/blogger, wrote on Jan. 15, 2014 that in a recent survey, “community pharmacists repeatedly cited having their supplies or shipments of controlled substances abruptly shut off by their wholesalers, which may have been done due to perceived pressure, intimidation or a lack of clear guidance from law enforcement officials, such as the Drug Enforcement Administration [DEA].”
Beginning the first week in January, many of our patients at Carolina Pain Associates notified me that they are affected by this crisis. The pharmacies they used for years to fill their pain medication prescriptions no longer stocked them; many [pharmacies] did not know if and when they would be receiving these drugs. Some patients were referred to alternative pharmacies; in other cases, the pharmacist was uncertain where [the patients] could go to get their prescriptions filled.
Patients became extremely anxious that they would go through withdrawal from abruptly stopping their medications; many became desperate and called for emergency appointments. Some who tried to fill prescriptions on a weekend used the emergency room (which, of course, is an inappropriate use of this service). Others, in desperation, turned to the “street.” I need to emphasize that most of these individuals do not have a history of substance abuse and are not trying to get high; they are trying to get their needed pain medication and avoid withdrawal.
I should also note that some patients had to go to as many as seven or eight pharmacies before they could get a prescription partially filled; at times, they could only get enough medication to last one week instead of one month. These patients then must return to their pain physician’s practice to receive an additional prescription to cover the rest of the month. Some of our patients had to make emergency appointments with our office to see if there was an alternative, easier-to-obtain medication. Some of these patients were doing extremely well and had normalized their lives and improved their quality of life, and now were faced with having to abruptly discontinue the medications that had helped them, and begin on a new medication trial.
Anecdotal reports from pain practitioners and clinical pharmacists indicate that in some (often rural) areas, there were reported suicides, multiple emergency room visits, hospitalizations and other similar unfortunate events related to lack of needed pain medications. We are witnessing a crisis in health care, and I believe we will see that some patients who did not have a history of substance abuse may, out of desperation, consider these routes. How did we reach this point?
In 2008, I was president of the American Academy of Pain Medicine, the pain medicine physicians’ organization with the mission of optimizing the health of pain patients and eliminating the major public health problem that is chronic pain by advancing the practice and specialty of pain medicine. During that year, I was pain consultant to the Federation of State Medical Boards. One of my goals was to provide education on the importance of and guidelines for the appropriate manner of providing adequate analgesia to chronic pain patients.
The vast majority of legitimate chronic pain patients are not substance abusers or dependents. Chronic pain patients are generally monitored by their pain physicians or other providers to ensure that they use their prescribed medication to alleviate their severe pain, and improve functional daily activities and quality of life. In so doing, they often become more productive in many areas (e.g., social, vocational and educational).
I contrast this with the untreated substance abuse/dependent population, commonly known as drug addicts, whose use of drugs is dysfunctional and includes craving, loss of control over their drug use, compulsive drug use, continued use despite harm and at times diversion of medications to sell. They do not take drugs for their therapeutic value.
It is inappropriate to penalize legitimate chronic pain patients because of substance abusers. If, indeed, the DEA is involved in withholding/limiting from the pharmacist opioids and other controlled substances used therapeutically for a large population of chronic pain patients in an attempt to curtail substance abuse, I believe the agency is going about this incorrectly, and needs to recognize the unintended harmful consequences of its actions.
Over the many years that I have had the opportunity to interact with the DEA regarding appropriate and inappropriate uses of drugs, I have generally found the agency willing to discuss ways to remedy the clinical problems discussed in this letter. My hope, for the sake of the large population of chronic pain patients in need of their medication, is that the DEA, and anyone else involved in this evolving crisis, will look for alternative ways to approach the problem.
Gerald M. Aronoff, MD
Medical Director, Carolina Pain Associates
Past president, American Academy of Pain Medicine