In response to a backlash against her bill imposing a nationwide seven-day limit on initial prescriptions of opioids for acute pain, Sen. Kirsten Gillibrand (D-N.Y.) suggests she is open to changes that would address the concerns raised by critics. Gillibrand's acknowledgment of the criticism is encouraging, but her response seems confused, wrongheaded, and disingenuous.
"I want to get this right," the presidential contender writes on Medium, "and I believe that we can have legislation to help combat the opioid epidemic and the over-prescription of these powerful drugs without affecting treatment for those who need this medication. I fundamentally believe that all health care should be between doctors and patients, and this bill is not intended to interfere with these decisions but to ensure doctors prescribe opioids with a higher level of scrutiny, given their highly addictive and dangerous effects."
If "legislation to help combat the opioid epidemic" includes an arbitrary limit on the length of these prescriptions, there is no way that it won't affect "treatment for those who need this medication." It is impossible to reconcile such a one-size-fits-all rule, which doctors would have to follow if they want to legally prescribe controlled substances, with Gillibrand's avowed commitment to not "interfere" in the doctor-patient relationship. Her bill, which is co-sponsored by Sen. Cory Gardner (R-Colo.), is designed to interfere in that relationship and to override physicians' medical judgment. If it did not do that, there would be no point to it.
To be fair to Gillibrand, she did not invent the seven-day rule, which at least a dozen states have imposed in the last few years, according to a tally by National Conference of State Legislatures. Several others have imposed shorter limits. Legislators in Arizona, New Jersey, and North Carolina have decreed that five days is plenty; Minnesota settled on four; and Florida and Kentucky say three, which is the national rule that Sen. Rob Portman (R-Ohio) proposed last year, prompting criticism from the American Medical Association. Medicare began enforcing a seven-day limit at the beginning of this year.
These legislators and bureaucrats all seem to be taking their cue from the opioid prescribing guidelines that the U.S. Centers for Disease Control and Prevention (CDC) published in March 2016. "When opioids are used for acute pain," the CDC says, "clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed." Legislation like Gillibrand's takes this advice and makes it mandatory, while ignoring the qualifications. Saying that three days is "often sufficient" obviously does not mean it is always sufficient, and even if more than seven days is "rarely" needed, it sometimes is.
A study reported last year in JAMA Surgery found that the prescription length associated with the lowest probability of a refill was nine days for general surgery, 13 days for women's health procedures, and 15 days for musculoskeletal procedures. "In practice," the researchers concluded, "the optimal length of opioid prescriptions lies between the observed median prescription length and the early nadir," i.e., the point where a refill was least likely.
That rule of thumb would put the optimal prescription length between four and nine days for general surgery, between four and 13 days for women's health procedures, and between six and 15 days for musculoskeletal procedures. "Although 7 days appears to be more than adequate for many patients undergoing common general surgery and gynecologic procedures," the researchers wrote, "prescription lengths likely should be extended to 10 days, particularly after common neurosurgical and musculoskeletal procedures, recognizing that as many as 40% of patients may still require 1 refill at a 7-day limit."
There is no dispute that doctors sometimes prescribe more pain medication than patients end up needing, and leftover pills from those prescriptions may be diverted to nonmedical use (or saved in case they are needed for another painful condition, which the government still considers "misuse," although someone who takes a pill originally prescribed after oral surgery when he throws out his back would probably disagree with that characterization). Bills like Gillibrand's force doctors to err in the opposite direction, which means some patients will suffer from pain that could have been relieved. And even if some of those patients manage to get additional prescriptions, the upshot could be that more pills are prescribed than otherwise would have been: two seven-day prescriptions, say, instead of the 10 days that would have sufficed.