This is interesting (via NYT):
Move to Restrict Pain Killers Puts Onus on Doctors
The effort, in Washington State, represents the most sweeping attempt yet to stem what some experts see as the excessive use of prescribed narcotics, and it is being closely watched by medical professionals elsewhere. Among other things, Washington would apparently become the first state to require a doctor to refer patients on escalating doses of pain killers for evaluation if they were not improving.
Experts in pain treatment and drug abuse prevention say the growing use of long-acting pain killers like OxyContin, fentanyl and methadone has been a crucial factor in a nationwide epidemic of overdose deaths, largely from the abuse of such drugs.
Drug makers and patient groups have complained that new restrictions would unfairly punish pain sufferers who rely on the drugs. Others, including some doctors and regulators, have argued that the drugs are potentially so dangerous that they need to be even more tightly controlled.
However, the Washington State initiative appears to reflect a growing view that the status-quo is no longer acceptable. Last Friday, an advisory panel to the Food and Drug Administration overwhelmingly rejected an agency proposal to better control drugs like OxyContin as too weak because it did not require special training for doctors who prescribe such medications.
The effort in Washington is also directed at controlling how doctors use narcotics to treat legitimate pain patients, not at people who illegally obtain the drugs for recreational use. While many patients benefit from pain killers, there is growing evidence from studies, including one in Washington State, that others suffer significant side effects, including lethargy, increased sensitivity to pain and, in the most severe instances, potentially fatal overdoses. [...]
The panel is expected to require that, among other things, doctors refer patients to a pain specialist for review when their daily medication increases to a specified dosage level and they do not show improvement. The specialist can then determine whether to continue the drug, reduce it or use other treatments like physical therapy.
Recently, the Centers for Disease Control issued a similar recommendation to doctors.
Pain specialists and regulators in Washington State said they thought the requirements were essential because doctors were giving high daily dosages of powerful drugs for ailments like back pain for far too long without evidence that the drugs worked.
The law that created the new regulatory effort in Washington State did not propose specific sanctions or penalties. However, officials there said that a doctor who chose to ignore the new rules could face sanctions from state licensing boards, including potentially losing the right to practice. The company that makes OxyContin, Purdue Pharma, lobbied against the law, saying the new regulations could deprive patients of appropriate treatment.
The initiative sprang out of the efforts of Dr. Cahana and two other people, including a Washington State representative, James C. Moeller, who is also a substance abuse counselor.
Mr. Moeller, who works at a facility in Vancouver, Wash., run by Kaiser Permanente, said he had treated a steady procession of patients in recent years, nearly all of them young and physically dependent or psychologically addicted to high dosages of pain killers.
In the process, Mr. Moeller said, he realized that many doctors who prescribed such drugs had little training in either pain management or substance abuse. So, wearing his legislator’s hat, he drafted a bill to require doctors to take a training course to prescribe narcotics.
He said he quickly encountered opposition to the idea from a professional group that represented doctors. [...]
“There is a dissonance in not recognizing the nexus between poor pain management and the hyperconsumption of opioids,” said Dr. Cahana, who works at the University of Washington Medical Center in Seattle, using a medical term for narcotic pain killers like OxyContin.
Dr. Franklin, whose department oversees the state’s workers’ compensation program, said he had long seen the problem play out among claimants. “Injured workers were coming into the system with low back pain and dying two or three years later” from drug overdoses, he said.
This year, Dr. Cahana and Dr. Franklin testified during a legislative hearing on the proposed training requirement, suggesting that legislation should instead require a set of medical practices based on the best available evidence. Dr. Franklin said that a draft of rules would probably be finished by this fall and that the new regulations would be in place by next year.
A major hurdle to making the program work is the lack of pain management specialists, particularly in rural areas of the state, where patients could be referred for evaluation. Dr. Franklin said the state hoped to increase the use of telephone consultations as well as help to finance the training of doctors in pain treatment.
I'm not sure what to think about this. I've been pretty appalled by the proliferation of narcotic super-users, people on what you might call "hyper-doses" of pain meds for chronic and incurable conditions. The most striking thing I have noticed is the high likelihood, when I see a patient on 160mg of oxycontin TID, is that it's not working, and they are still complaining of uncontrolled pain! I can concede that there is a selection bias in the ER and I am more likely to see people whose pain is uncontrolled by the nature of the setting. However, it is striking that the pain specialists seem to have a similar experience. I really think that it would be an overall social good if the wanton use (because it is in many cases wanton) of these medications by non-pain-specialists were reined in.
But. (You knew there was a but coming, right?)
It's inarguably true that there are not and will not be in the foreseeable future enough pain specialists to see all the people who might need this "referral." Medicaid patients (who are more likely to be on chronic pain medicines because there is a high correlation between chronic pain, disability and the poverty that qualifies one for medicaid) have it even worse since pain specialists are no more willing to see money-losing patients than any other office-based physician is.
There's a similar concern regarding the requirement for special training requirements for doctors to prescribe Oxys and the like, since my experience is that many primary care doctors are reluctant to take these course and might simply use it as a pretext to stop prescribing these drugs at all. So the effect might be that many patients, many who are appropriately treated, might simply get cut off.
It's a tough problem. I don't see an easy solution, or any solution without significant risks. But it is clear that the status quo is not acceptable and that something needs to be done.