The Arizona Opioid Epidemic Act, the culmination of months of outreach and planning by state health officials, was passed earlier this year with unanimous support.
It started in June 2017, when Arizona Gov. Doug Ducey, a Republican, declared a public health emergency, citing new data, showing that two people were dying every day in the state from opioid overdoses.
He has pledged to come after those responsible for the rising death toll.
“All bad actors will be held accountable – whether they are doctors, manufacturers, or just plain drug dealers,” the governor said in his annual State of the State address, in January 2018.
He cited statistics from one rural county in which four doctors prescribed 6 million pills in a single year, concluding “something has gone terribly, terribly wrong.”
Later in January, Gov. Ducey called a special session of the Arizona legislature and, in less than a week, he signed the Arizona Opioid Epidemic Act into law. He called it the “most comprehensive and thoughtful package any state has passed to address this issue and crisis to date.”
The law expands access to addiction treatment, ramps up oversight of prescribing and protects from prosecution drug users who call 911 to report an overdose, among other things.
Initially, Arizona’s major medical associations cautioned against what they saw as too much interference in clinical practice, especially since opioid prescriptions already were on the decline.
Gov. Ducey’s administration offered assurances that the law would “maintain access for chronic pain sufferers and others who rely on these drugs.” Restrictions would apply to new patients only. Cancer, trauma, end-of-life, and other serious cases were exempt. Ultimately, the medical establishment came out in favor of the law.
Pressure on doctors
Since the law’s passage, some doctors in Arizona report feeling pressure to lower patient doses, even for patients who have been on stable regimens of opioids for years without trouble.
Julian Grove, MD, knows the nuances of Arizona’s new law better than most physicians. A pain physician, Dr. Grove worked with the state on the prescribing rules.
“We moved the needle to a degree so that many patients wouldn’t be as severely affected,” said Dr. Grove, president of the Arizona Pain Society. “But I’ll be the first to say, this has certainly caused a lot of patients problems [and] anxiety.”
“Many people who are prescribing medications have moved to a much more conservative stance and, unfortunately, pain patients are being negatively affected.”
Like many states, Arizona has looked to its prescription-monitoring program as a key tool for tracking overprescribing. State law requires prescribers to check the online database. Report cards are sent out comparing each prescriber to the rest of their cohort. Clinicians consider their scores when deciding how to manage patients’ care, he said.
“A lot of practitioners are reducing opioid medications, not from a clinical perspective, but more from a legal and regulatory perspective for fear of investigation,” Dr. Grove said. “No practitioner wants to be the highest prescriber.”
Arizona’s new prescribing rules don’t apply to board-certified pain specialists like Dr. Grove, who are trained to care for patients with complex chronic pain. But, he said, the reality is that doctors – even pain specialists – were already facing pressure on many fronts to curtail opioids – from the Drug Enforcement Agency to health insurers down to state medical boards.
The new state law has made the reduction of opioids only “more fast and furious,” he said.
Dr. Grove traces the hypervigilance back to guidelines put out by the Centers for Disease Control and Prevention in 2016. The CDC spelled out the risks associated with higher doses of opioids and advised clinicians when starting a patient on opioids to prescribe the lowest effective dosage.
Sally Satel, MD, a psychiatrist and a fellow at the American Enterprise Institute, said those guidelines stipulated the decision to lower a patient’s dose should be decided on a case-by-case basis, not by means of a blanket policy.
“[The guidelines] have been grossly misinterpreted,” Dr. Satel said.
The guidelines were not intended for pain specialists, but rather for primary care physicians, a group that accounted for nearly half of all opioids dispensed from 2007 to 2012.
“There is no mandate to reduce doses on people who have been doing well,” Dr. Satel said.
In the rush to address the nation’s opioid overdose crisis, she said, the CDC’s guidelines have become the model for many regulators and state legislatures. “It’s a very, very unhealthy, deeply chilled environment in which doctors and patients who have chronic pain can no longer work together,” she said.
Dr. Satel called the notion that new prescribing laws will reverse the tide of drug overdose deaths “misguided.”
The rate of opioid prescribing nationally has declined in recent years, though it still soars above the levels of the 1990s. Meanwhile, more people are dying from illicit drugs like heroin and fentanyl than prescription opioids.
In Arizona, more than 1,300 people have died from opioid-related overdoses since June 2017, according to preliminary state numbers. Only a third of those deaths involved just a prescription painkiller.
Heroin is now almost as common as oxycodone in overdose cases in Arizona.