A Real Pill
Prescription rules pit addiction activists against medical groups
By Margaret Wright
Legislation that aimed to curb the state's epidemic rates of opioid abuse and overdose deaths became a hot-button issue during the 30-day legislative session.
One bill sponsored by Bernadette Sanchez (D-Albuquerque) would have set restrictions on opioid prescriptions. Among them: No refills. For dental issues, a prescription could not exceed a three-day supply. For other medical conditions, prescriptions could not exceed a month's supply.
But those limits were axed entirely before the measure made it out of committee.
The legislation met resistance from several medical associations. In a briefing paper, the influential New Mexico Medical Society argued that restrictions would mandate a “cookie-cutter” approach to pain management. It could also create a situation in which physicians may refuse to take care of chronic pain patients and may even be discouraged to prescribe narcotic medications to those who need them.
Dr. Miriam Komaromy is an addiction specialist and the executive director of state-funded treatment hospital Turquoise Lodge. She contends medical organizations should be at the forefront of combating the opioid problem, and making regulations clear and accessible to physicians.
The bill also required that all first-time patients receiving opioids be educated about the risks and sign a consent form. A companion measure would create a better version of the state's prescription drug monitoring program, which Komaromy says is not an effective tool for tracking patterns of prescription misuse. “It’s not the worst, but it’s far from the best,” she says. “We have no dedicated staff or ongoing funding, so we don’t have the ability to do much beyond an individual query.”
Doctors wait 24 to 48 hours before receiving responses about specific patients, she explains, and pharmacies typically lag 30 to 60 days behind in entering prescription updates into the database.
Gov. Susana Martinez was confident at the beginning of the month that the legislation would see “strong bipartisan support.” A diluted version of the restriction measure cleared the Senate on Saturday, Feb. 11. As this issue went to press, it seemed possible that the database would be approved, but long-term funding remained uncertain. (Go to alibi.com for updates.)
Jennifer Weiss, president of the Albuquerque-based Heroin Awareness Committee, lost her teenage son in August to a heroin addiction that she says evolved out of a legal prescription for opioid painkillers. She says opposition from segments of the medical community is frustrating. “We have a huge problem in our state with people becoming addicted to prescription opiates that subsequently lead to heroin addiction. And some of the legislators and doctors aren’t putting the pieces together that overprescribing is directly tied to the addiction rate.”
The Centers for Disease Control in 2011 declared opioid addiction and resulting deaths a national epidemic. New Mexico ranks among the highest for both and has held that place for years. The National Institute on Drug Abuse indicates that the medications have become so commonplace, it’s easy for consumers to think they’re totally safe.
Doctors write prescriptions that often sit unmonitored in family homes, according to a study in the International Journal of Drug Policy. It states that prescription drug abusers easily obtain their fix from friends or family members with legal access. A recent CNN report found that opioids can be sold illegally from $5 to $80 per dose.
The street value is an incentive for doctor shoppers—addicts or pill pushers who secure prescriptions from multiple physicians. But the expense could lead a pill addict to seek heroin when money’s tight. Pills can cost more than a small bag of heroin, according to the Heroin Awareness Committee.
Komaromy says too many medical professionals with prescription licenses are in denial about the extent of the crisis. “Physicians have some awareness of the problem of opiate addiction and overprescribing, but they never think it’s their patients," she says. "They think they’d know if someone’s addicted. They’re sure they adequately warn all their patients about the need to protect their opiate meds and not take more than they need. It just objectively is not true.”
An Unexpected Struggle
While opponents of the legislation say they agree with its intent, they lobbied hard—and effectively—against many of its restrictions.
The New Mexico Medical Society walks a fine line in protecting the interests of both patients and physicians, says President Karen Vaillant, who's also a doctor. The group wants to prevent future tragedies, she says, and it supports the concept of the bill. But, she adds, "No one wants their mother to be left in pain because of a specific law.”
Vaillant says although the group’s briefing paper recommended that the bill not pass, it and other medical groups worked closely with Sen. Sanchez, the bill’s sponsor, on a compromise. Controversy, says Vaillant, is simply an inevitable result of the democratic process.
Harris Silver, a retired surgeon and teacher at the UNM’s School of Medicine, is a proponent of Sen. Sanchez’ reforms, serving as an expert witness during legislative testimony. He characterizes the battle differently. “They brought us down to our knees, basically,” says Silver. “It ended up with a couple of good things in it, but I don’t think we’re going to save a lot more lives with the effort as it is now.”
Komaromy says physicians are generally against regulation. Doctors are tired of being told how to practice medicine by HMOs, politicians and insurance companies, she explains. Still, she insists, the opioid problem is too severe to ignore. “There aren’t other medications that cause anything like these rates of death. It’s estimated that one in 20 people who take prescribed opiates will become addicted, and yet the idea that we would require informed consent is met with horror.”
As the final days of the legislative session slipped by, a compromise was reached in committee: An Opioid Prescribing Council made up of licensing boards, consumer advocates and pain specialists could be tasked with developing rules by the end of the year.
Reworded legislation doesn’t require written consent but indicates that doctors report a conversation about opioids with a patient took place. It also states that limits on prescriptions and refills will, at minimum, need to exceed those set by the federal Drug Enforcement Administration.
The DEA allows prescribers to dole out painkillers in up to 90-day increments with refills. Advocates fear the opioid prescribing council still won’t come up with rules as stringent as the original legislation. “Physicians haven’t chosen to regulate themselves in the decade that we’ve led the nation in overdose deaths,” says Komaromy. “It was time for someone else to step in and come up with some reasonable restraints.”
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