Refine opioid rules for palliative care

Opioid misuse here is low compared to hot spots on the mainland. Still, like many other states, for about a decade now Hawaii’s count of annual drug poisonings has been out-pacing injuries tied to motor vehicle accidents as the leading means of fatal injuries.

That’s reason enough to put in place tough state legislation to help curtail the trend while also strengthening prevention and treatment efforts.

And in recent years, that’s what Hawaii has done with legislation that sets prescription limits, requires drug label warnings, increases access to overdose reversal meds such as naloxone and other opioid antagonists, and allows “Good Samaritan” amnesty for individuals who call 911 to prevent a drug or alcohol overdose from becoming fatal.

That’s all for the good to spare Hawaii the level of opioid-related devastation seen on the mainland. So far, more than two dozen states have implemented laws or policies limiting opioid prescriptions in some way.

However, the combination of stepped-up state vigilance and an ongoing national crackdown — based in part on Centers for Disease Control and Prevention directives — is leaving some chronically ill patients in Hawaii and elsewhere with unwarranted high hurdles to clear to simply fill their regular pain-control prescriptions.

When the 2019 Legislature convenes, lawmakers should examine whether our lineup of measures to reduce the scope of the opioid problem and related substance misuse can be amended to avoid undue restrictions on palliative care. Also, on the national level, Hawaii’s congressional delegation should guard against hyper-vigilance.

Honolulu Star-Advertiser reporter Kristen Consillio spotlighted such as a case in a recent interview with Patricia Borman, a longtime family medicine practitioner who specializes in geriatrics and pain management.

Because one of her patients — a Vietnam War vet who takes medication to relieve pain tied to combat injuries and neuromuscular disease — is prescribed dosage that’s higher than what’s deemed as standard, the Veterans Administration pharmacy is now trying to negotiate lower dosages.

“In a sense, they’re telling me how to prescribe for this guy,” Borman said. She added, “My patients and I are made to feel like criminals to obtain these important medications.” Pain specialists like Borman should be exempt from rising hurdles that are allowing insurance companies and pharmacies to essentially restrict practice of medicine.

In 2016, the CDC issued its take on the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage. Some observers say those guidelines, which stipulated the decision to lower a dose should be decided on a case-by-case basis — not by means of a blanket policy — have been misinterpreted.

That seems plausible. Primary care physicians as a group — not pain specialists — reportedly accounted for nearly half of all opioids dispensed from 2007 to 2012, according to the CDC. A clear-cut exemption should be in place for palliative care patients and their doctors who are being smothered by the apparent blanket approach.

The ongoing crisis has roots reaching back to the 1990s when pharmaceutical companies assured health care providers and others that patients would not become addicted to prescription opioid pain relievers, prompting a movement in which prescriptions for medicines like OxyContin and Vicodin were written at greater rates.

That led to widespread misuse before it became clear that these medications could indeed be highly addictive. Flash forward to 2018: This month, the Drug Enforcement Administration said in its National Drug Threat Assessment that heroin, fentanyl and other opioids continue to be the highest drug threat in the nation.

It’s encouraging that in late September the U.S. Department of Health and Human Services announced the issuing of more than $1 billion in opioid-specific grants to help states. Hawaii received $8 million, which is earmarked for prevention programs as well as treatment and recovery initiatives.

The latest CDC data shows there were more than 70,000 U.S. drug overdose deaths last year, including more than 47,000 from opioids, the highest numbers on record. What’s more, those numbers are a leading factor in the decline of U.S. life expectancy over the past three years.

Clearly, an aggressive and sustained strategy is needed to curb the crisis, even in Hawaii, where opioid death rates have historically been on the low side. In 2016, there were 77 opioid-related overdose deaths­­­ here — a rate of 5.2 deaths per 100,000 persons, which is less than half the national rate of 13.3 deaths.

Last year, Hawaii’s count dropped lower, thanks in part to the new legislation and national vigilance. The need for tweaks, such as for a sort of palliative care exemption, is to be expected when settling into a daunting public health strategy. When they surface, our elected leaders should move quickly to make adjustments to facilitate sensible health care.