Christopher J. Winfree, MD, FAANS
Department of Neurological Surgery, Columbia University
New York, NY
Ever since the Affordable Care Act (ACA) was passed in 2010, there has been increased attention paid to the use of opioids to treat chronic pain in America. Much of this has been in response to a worsening opioid crisis for patients and non-patients have had access to increasing supply of powerful opioid pain-relieving medications. Ready access to these drugs has enabled patients, and sometimes their family members, to become addicted to these medications. This commonly leads to heroin or synthetic opioid abuse. It is important to note that more patients are dying of opioid overdose than of car accidents, which is a pretty remarkable statistic. At this time, the Trump Administration is considering declaring a national emergency over the developing opioid crisis in America.
Given that this crisis is at least partially due to the abundance of readily-available and powerful opioid medications, efforts to reduce the illicit use of opioids as well as their overall availability seem reasonable. Efforts to limit the use of opioids to clinical situations that warrant their use and minimize access to these drugs to patients who do not need them should be applauded. The routine use of prescription drug monitoring programs and opioid contracts for chronic opioid users are examples of laudable efforts to optimize the prescribing of opioids.
Additionally, several states have enacted legislation limiting the prescribing of opioids for acute pain to short periods of time. Arizona, New York, Delaware, and Pennsylvania are examples of states that have a seven-day limit. New Jersey has the strictest law, allowing only a five day supply of opioids. Generally, the limitations do not apply to patients with chronic pain, cancer pain, or in a palliative care program. Pennsylvania allows for longer-term prescribing than seven days if the treating physician documents the medical necessity of the increased opioid prescription and the absence of non-opioid alternatives. Earlier this year, Sens. John McCain (R-Ariz.) and Kirsten Gillibrand (D-N.Y.) coauthored S. 892, the Opioid Addiction Prevention Act, which would restrict postoperative pain medications nationwide to a seven day supply, similar to the state laws already in place. Reps. Phil Roe, MD (R-Tenn.) and Ann Kuster (D-N.H.) have introduced similar legislation (which is more flexible and allows a 10-day supply) by the same name, H.R. 3964, in the House of Representatives. No action has yet been taken on these bills.
In theory, such legislation makes sense if the aim is to limit the supply of new drugs to the general population of opioid-naïve patients presenting to the emergency room with a new, acute pain syndrome. In most cases, a one week supply of opioid medication is sufficient to either adequately treat the patient through the pain episode, or at least treat them until they can follow-up with their outpatient physician for further management.
Unfortunately, this legislation creates an unacceptable hardship for a subset of neurosurgical patients who require opioid medications to treat acute pain that is expected to last longer than one week. Patients who undergo complex spine surgery, such as fusions and scoliosis reconstructions, will almost always require longer-term opioid administration, sometimes lasting several weeks. Head trauma patients who also require management of other painful orthopedic or abdominopelvic trauma often need opioid pain medication lasting longer than one week. Given that all opioid prescriptions require a face-to-face visit with the prescriber, the expectation that a convalescing polytrauma or scoliosis patient will be able to make weekly visits to their physician for an opioid prescription is ridiculous. What will happen in many cases instead, is that patients will not make these appointments and their pain will go undertreated. This will have a detrimental effect on outcomes, as the patient in severe pain will be less likely to mobilize and participate in therapy. A blanket limitation of all opioid prescriptions for acute pain for five to seven days will no doubt hurt many of our neurosurgical patients.
To protect our acute pain patients that require opioids for longer than one week, the AANS, CNS and the AANS/CNS Joint Section on Pain recently sent a letter to Sens. McCain and Gillibrand requesting that the bill allow exceptions for these patients. This should not be a blanket exception weakening the law, but an exception only in specific clinical circumstances that the physician deems appropriate for patients requiring more aggressive opioid management. Such an exemption would be similar to that present in Pennsylvania opioid prescribing law, which allows longer prescriptions than one week when clinically appropriate and sufficiently documented by the treating physician. Our hope is that such an exemption will ensure that our neurosurgical patients who undergo complicated and painful surgical procedures can continue to access vital post-operative pain management strategies.
State and Federal governments have made it clear that restricting opioid prescribing is an essential strategy in reducing the opioid crisis in America. This will hopefully reduce the vast amount of unneeded opioid medications in circulation. As physicians in general, and neurosurgeons specifically, we need to remain active in this legislative process to ensure that our patients continue to have access to the medically-necessary opioids to treat their severe pain, and not be improperly denied access to these crucial medications when most needed.
Editor’s Note: We encourage everyone to join the conversation online by using the hashtag #painfacts.