I am posting this letter in response to the Governor’s recent State of the State address as it pertained to the every-growing problem of prescription narcotic abuse and the unacceptable number of deaths due to opioid overdose.  

As an introduction, I am a practicing radiation oncologist and Past President of Medical Staff at Southern Ocean Medical Center in Manahawkin New Jersey and Deputy Mayor of Long Beach Township New Jersey. From a clinical perspective, a large portion of my practice involves chronic pain management. As Deputy Mayor I am intimately involved in local issues and formally responsible for oversight of the Long Beach Island Health Department. Therefore, with leadership responsibilities as both a front line medical provider and a community leader I feel compelled to express my concerns over the proposed governmental regulation of narcotic prescription usage and the NJ Medical examiners persecution of physicians dealing with this challenging issue. 

Government Does a 180 on Pain Management - Patients will suffer- Overdoses Will Likely Continue to Skyrocket

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After an impassioned state of the union address by the Governor with respect to the prescription drug problem, there is little doubt that the government is serious in their effort to “fix this epidemic.”  I do not doubt the sincerity of the governor’s intentions as he laments the sad story of a colleague ultimately overdosing from narcotics.  However, as with most issues, effective solutions to complex problems cannot be solved by legislative decree. (a bill has been proposed to limit narcotic use to only three days).   Furthermore, the governmental bodies, led by the state medical board are exacerbating the problem by aggressively sanctioning primary care physicians who have been caring for many of these patients. Until recently, there have been no “bright line” guidelines to delineate best practice when prescribing narcotic analgesics.

While no one disputes there has been a significant rise in the utilization of narcotic medications in this country, defining effective solutions requires an assessment of the underlying causes of such trends. In the early 1990’s there was a significant push by the medical establishment, largely driven by pharmaceutical manufactures, to attack the problem of unrecognized or under treated chronic pain. This was championed by many organizations and made famous by a pain specialist Dr Portenoy. This led to establishing pain as the “fifth vital sign” which garnered widespread support from pain management societies, nursing societies and even the JCHO. The underlying premise suggested that the general medical community was not adequately addressing the problem and underutilizing “very effective” narcotic medications. Patients were at the time told they “had a right” to not experience pain. There was no regulatory or professional guidance offered as to best practice in treating chronic pain.
There have been many causes and solutions proposed for the problem. The only facts not in dispute regarding the problem are that narcotic prescription utilization has skyrocketed since 2000. With the wisdom of hindsight those same individuals that once championed greater use of narcotics suggest that there may be harmful risks to chronic opioid usage. While the data remains controversial that patients with no history of drug abuse problems become addicted to opioid medication, the political pendulum has clearly swung in the opposite direction. We now see politicians suggesting that the physicians, not the policy is responsible for the spike in narcotic and heroin use in our communities. The medical community is acutely aware of the new federal guidelines established by the CDC and the subsequent support by the surgeon general to reduce narcotic pain usage in non-oncologic patients. I am not suggesting that either the office of the NJ Attorney General, the Governor nor the Medical Examiner’s office enter into a debate as the cause and effect of such policies but rather to consider the position of the practicing physician in the community whom must deal with the ever-changing position of theses largely bureaucratic organizations. The volume of patients with non-oncologic chronic pain is staggering. It is foolish and impractical to suggest that all of these patients can be managed by a pain medicine specialist. Therefore, as a practical matter a large portion of chronic pain patients are currently being managed in the primary care office. These physicians are now challenged with the difficult task of weaning patients with long-standing histories of opioid exposure. This is a process that will undoubtedly take considerable time and social support as well as resources to accomplish. 
Concurrently as the federal and state governments change their perspective and subsequently the guidelines on narcotic prescriptions, the NJ Medical board is taking an aggressive stance against physicians who care for these patients.  These primary care physicians are now placed in a difficult situation of managing patients with long standing histories of chronic pain syndromes.  By statute they will be required to abruptly reduce or discontinue patient’s medications or face the potential of licensure forfeiture.  The governing bodies have suggested that these patients should be referred to pain management physicians.  The primary care physicians would like nothing better than to make that referral.  However, what you won’t hear from the Governor is that not only are there not sufficient numbers of pain specialist to handle the problem but that the pain specialists are not enthusiastic to accept these difficult patients.  As the law of unintended consequences begins, patients are being denied renewals for their medications for fear of significant reprisal from the sanctioning bodies.  As a direct consequence, they turn either to emergency rooms or the street for relief. While I will admit, I have not read all the details of the bill I suspect this will increase anxiety from the medical community further driving these patients “underground.”  Most persons would not be surprised to learn that the support services (counseling, addiction programs etc.)  are presently severely lacking to all but the most affluent individuals in NJ.   What this often leads to is these patients seeking heroin which unfortunately is now often contaminated with a Fentanyl derivative. This combination is largely responsible for the spike in Ocean County narcotic related deaths.  This phenomenon is not conjecture as a 2012 article in the New England Journal of Medicine documented that when an abuse deterrent Oxycontin formulation was prescribed and the availability of prescription narcotics became limited, most addicts switched to heroin as “it is easier to use, much cheaper, and easily available.”

The irony of this situation is that I largely agree with the Governor and the findings of the CDC.  There is little doubt that far too many patients with non-oncologic pain are receiving narcotic medications.  The problem is that this will require a much more comprehensive approach that what I have seen proposed.  Admittedly there are appropriations for counseling and addiction programs inside the bill.  I firmly hope that we do increase funding for these much-needed services. However, it cannot be understated that the medical community does not have the capacity to make radical shifts in practice.  The politicos fail to appreciate what is occurring in the community as it relates to what is going to be a very abrupt and disruptive change in prescribing habits by a large portion of the physician community.  I believe that in stark contrast to the intended goal of better non-narcotic pain management, the result, at least in the near term, will be a significant spike in street acquired drug use resulting in an increase overdose deaths. The solution to this complex problem is a more thoughtful and inclusive implementation of the guideline recommendations.  This must also be performed in cooperation with the Medical community and a NJ state board that more readily recognizes the difficult position of practitioners trying to best serve their patients.   I would encourage patients that are being affected by this policy shift to contact their State legislature and NJ medical examiner’s office to express their concerns

Joseph Lattanzi MD