“IF EVER ONE THINKS THEY’RE TOO SMALL TO MAKE CHANGES, THEN THEY HAVE NEVER SLEPT IN BED WITH A MOSQUITO !!!”
BY
NORMAN J CLEMENT RPH., DDS, NORMAN L. CLEMENT PHARM-TECH, MALACHI F. MACKANDAL PHARMD, BELINDA BROWN-PARKER, IN THE SPIRIT OF JOSEPH SOLVO ESQ., INC.T. SPIRIT OF REV. C.T. VIVIAN, JELANI ZIMBABWE CLEMENT, BS., MBA., IN THE SPIRIT OF THE HON. PATRICE LUMUMBA, IN THE SPIRIT OF ERLIN CLEMENT SR., WALTER F. WRENN III., MD., JULIE KILLINGWORTH, LESLY POMPY MD., CHRISTOPHER RUSSO, MD., NANCY SEEFELDT, WILLIE GUINYARD BS., JOSEPH WEBSTER MD., MBA, BEVERLY C. PRINCE MD., FACS., NEIL ARNAND, MD., RICHARD KAUL, MD., LEROY BAYLOR, JAY K. JOSHI MD., MBA, ADRIENNE EDMUNDSON, ESTER HYATT PH.D., WALTER L. SMITH BS., IN THE SPIRIT OF BRAHM FISHER ESQ., MICHELE ALEXANDER MD., CUDJOE WILDING BS, MARTIN NJOKU, BS., RPH., IN THE SPIRIT OF DEBRA LYNN SHEPHERD, BERES E. MUSCHETT, STRATEGIC ADVISORS
THIS IS HALLOWEEN
republished and reported in youarewithinthenorms.com
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“The atmosphere around prescribing for chronic pain had become so fraught that physicians felt they must avoid opioid analgesics even in cases when it contradicted their view of what would provide the best care for their patients. In some cases, this desire to cut back on opioid prescribing translated to doctors tapering patients off their medications without patient consent, while in others, it meant that physicians would no longer accept patients who had a history of needing high-dose opioids.”
KANSAS LAW REVIEW, VOL.67
BY
KELLY DINEEM RN, PH.D. ESQ.*
Jay Lawrence died by suicide after his providers unilaterally and too rapidly decreased his pain medication. They did so in response to the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (CDC Guideline or Guideline), despite the fact that the CDC Guideline is for primary care providers making decisions about beginning opioids in opioid naïve patients.
Guidelines did not apply to Jay, who had been on a stable dose of prescription opioids for years, nor did it apply to his providers, who were pain specialists, not primary care providers.
“Academies of Science, Pain Management, and the Opioid Epidemic, uses the terms overprescribing and inappropriate prescribing to describe a host of very distinct prescribing behaviors implicitly.
A comprehensive policy document by the Aspen Institute uses overprescribing imprecisely. Although many federal and state laws reference inappropriate prescribing, I was unable to locate any that actually defines inappropriate prescribing, overprescribing, or misprescribing.
The lack of definitional clarity for inappropriate prescribing in existing law and policy renders the responses like those of Jay’s providers predictable. It also compounds uncertainty in caring for patients with complex health conditions associated with opioids. It sets the stage for decreased quality of care, increased patient avoidance, and increased morbidity and mortality.
This overreaction to policy is not limited to providers. For example, third-party payors overcorrected in response to the Center for Medicare and Medicaid Services (CMS’s) guidance to utilize safety warnings for higher doses of opioids. CMS noted:
[W]e believed that some sponsors implemented these edits beyond their intended use . . . . [They] are not intended as a means to implement a prescribing limit or apply additional clinical criteria for the use of opioids, but instead to give physicians important additional information about their patient’s opioid use.
Policymakers and prescribers deserve better and more information as to what inappropriate prescribing means.”
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_________________________
* Assistant Professor and Director, Health Law Program, Creighton University School of Law. I am grateful for the many patients with chronic pain and the array of careful and compassionate providers with whom I have worked in the past, as well as the opportunity to work for and with Sandra H. Johnson, a pioneer in the use of law and policy to improve pain treatment. Those experiences deeply informed this article. As always, Sean Dineen is my champion and best proofreader—I am grateful for his constant support. Many thanks to John Bergstresser, who provided research assistance for this article and to Dr. Stacey Tovino, Victoria Haneman, and Greg O’Meara for their thoughtful comments. All of them made this article better. Any errors are mine alone. I published an abbreviated form of this article in the Hastings Center Report in 2018. See Kelly K. Dineen, Defining Misprescribing to Inform Prescription Opioid Policy, 48 HASTINGS CTR. REP. 4, 5–6 (2018).
1. Evan Anderson & Scott Burris, Opioid Treatment Agreements Are the Answer. What Is the Question?, AM. J. BIOETHICS, Nov. 2010, at 17.
2. Meredith Lawrence, How the CDC Guidelines Killed My Husband, 8 NARRATIVE INQUIRY BIOETHICS 219, 219 (2018); see also Meredith Lawrence, How Chronic Pain Killed My Husband, PAIN NEWS NETWORK (Sept. 6, 2017), https://www.painnewsnetwork.org/stories/2017/9/4/how- chronic-pain-killed-my-husband [https://perma.cc/AWA6-42PT] (“When the doctor took away Jay’s medications, they took away his quality of life. That was what led to his decision. Jay fought hard to live with his pain for a long time, but in the end, fighting just was not enough.”).
3. Lawrence, How the CDC Guidelines Killed My Husband, supra note 2, at 219 (“The decision to cut down his medication was based solely on his doctor’s misinterpretation of the CDC guidelines.”).
4. Deborah Dowell et al., Ctrs. for Disease Control & Prevention, CDC Guideline for Prescribing Opioid for Chronic Pain—United States, 2016, 65 MMWR RECOMMENDATIONS & REP. 1, 3 (2016), https://www.cdc.gov/mmwr/volumes/65/rr/pdfs/rr6501e1.pdf [https://perma.cc/DB3C-
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