June 23, 2023: ‘Legitimate’ pain patients struggle to fill opioid prescriptions as feds cut pill quotas, doctors say

A shortage of prescription opioids is causing people with severe pain to scramble to find their medicine, Long Island doctors and pharmacists say.

The federal government over the past decade drastically reduced the supply of legal opioid medication, in an effort to curb widespread abuse of the drugs. In addition, federal, state and private-industry monitoring of where those pills go greatly increased.

But doctors, pharmacists and patients say those initiatives went too far: People who have a legitimate need for the medicine now often have a hard time finding it, and sometimes must endure more pain after they run out of pills.

“I have a dozen messages every day from people saying their pharmacy doesn’t have” opioids, said Dr. Edward Rubin, a pain management specialist with offices in Garden City and Lake Success. Rubin said he is careful to prescribe opioids only to patients without good alternatives, particularly those recovering from major surgery.

Although fentanyl, much of it illegally manufactured, now kills a far greater percentage of people, the number of prescription-drug overdose fatalities in 2021 — 16,706 — is only slightly below the 2017 peak and five times more than in 1999, according to Centers for Disease Control and Prevention data. On Long Island in 2022, more than 700 people died of overdoses of legal and illegal opioids, most of them from fentanyl, Nassau and Suffolk officials said this week.

Rubin and other doctors and pharmacists put principal blame for the opioid shortage on the Drug Enforcement Administration’s declining cap on the amount of opioids pharmaceutical manufacturers can produce each year. For example, the DEA slashed the quota for the most widely produced opioid, oxycodone, which includes the brand names OxyContin and Percocet, from 164 million grams in 2013 to about 54 million in 2023.

“Continuing to throttle the legitimate supply is only hurting legitimate patients at the moment,” Rubin said.

Patients who can’t find their prescribed medicine are “switching medications, and we’re adding more risk … [because] I don’t know how they’re going to respond to a totally different medication,” he said.

Tom D’Angelo, owner of pharmacies in Franklin Square, Garden City and Point Lookout and former president of the Pharmacists Society of the State of New York, said the DEA should increase quotas so patients with legitimate pain needs can obtain relief.

He fears that some people in severe pain may resort to buying pills on the street, where something sold as oxycodone may actually be a potentially fatal dose of fentanyl.

Rationing pain-relief pills

John Douglas, 66, of Lake Grove, has been taking opioid medications for several years, first for neck pain, and now also for joint pain from prostate cancer drugs.

“I’m in pain constantly,” he said.

He’s tried several alternatives to opioids and, although the hydrocodone he takes “doesn’t give me 100% relief,” it reduces pain and allows him to work as a physical therapist assistant.

“I’m sick and tired of every time you go to the drugstore, you don’t know if your medicine is going to be there or not,” he said. “It’s just not right.”

People with legitimate pain who are using their medicine as prescribed are being “penalized” for those who abuse opioids, he said.

Patients nationwide have struggled to obtain their opioid medications. Hundreds of chronic pain patients, medical professionals and others submitted remarks to the DEA last year about the agency’s 2023 quotas, some expressing concern that decreases “have resulted in a shortage of opioid medications, interfered with the treatment of patients, and impacted the quality of life for patients possibly leading to suicide,” according to a DEA summary of comments released in December.

Critics, in comments submitted to the DEA and in statements from pharmaceutical executives and others, said DEA quotas on ingredients for attention deficit/hyperactivity disorder medications also are among the reasons for a nationwide shortage of those drugs.

The DEA in the December report said its quotas are set “in a manner to provide for all legitimate medical purposes.” It also said the limits “help prevent the misuse and diversion of pharmaceutical controlled substances,” and overdoses. A DEA spokeswoman declined to comment further.

The DEA acknowledged in the report that fewer than 1% of five common opioid medications were diverted for illicit uses. Numerous comments also pointed out that despite the drop in quotas, overdose deaths were up — especially from fentanyl and pain pills manufactured illegally outside the quotas.

Mary Silberstein, senior director of strategic alliances and special projects for Hicksville-based CN Guidance and Counseling Services, said restrictions on opioid supply and distribution were “much needed” and have saved lives.

“When you had so many people giving out the prescriptions in such large quantities, you had to have restrictions,” she said.

Opioid prescription rates drop on Long Island

The massive decrease in opioid quotas came after dramatic increases in the 1990s and 2000s. The quota for oxycodone, for example, rose from 3.5 million in 1993, before FDA approval of one of the most widely abused opioids, OxyContin, to its peak of 164 million in 2013. Other opioids had less extreme increases or were taken off the market.

Although the number of opioid prescriptions began falling after 2010, there still were about three times as many opioids prescribed in 2015 as in 1999, when calculated by “morphine milligram equivalents,” to account for differences in drug type and strength, according to a 2017 article in the CDC’s Morbidity and Mortality Weekly.

On Long Island, the number of opioid prescriptions per 100 people fell by more than half in Suffolk between 2012 and 2020, from 66.4 to 29.9, while Nassau’s rate decreased from 49.2 to 41.3, below the national rate of 43.3, according to the CDC. The rate includes people with multiple prescriptions in a year.

Experts say rates are declining in part because doctors turn to opioids more sparingly, and there are more controls to flag physicians who prescribe unusually large amounts of opioids. In the past, people abusing opioids “would doctor-shop,” said Dr. Paul Pipia, president of the Medical Society of the State of New York and deputy medical director of Nassau University Medical Center in East Meadow. “There was no way to know who went where.”

There now is an electronic registry of patients’ controlled-substance histories that the state requires medical professionals to review before writing prescriptions. A law capping initial opioid prescriptions for acute pain at seven days, with refills only after further evaluation, limits overprescribing, Pipia said.

Pharmacists say ceilings on how many opioids they dispense each month mean that even though the number of opioid prescriptions is declining, they can’t always fill them.

As part of a $21 billion settlement for their alleged role in the opioid crisis, the nation’s three largest pharmaceutical distributors agreed to increase their scrutiny of opioids and limit the quantity they send each pharmacy.

D’Angelo said if he runs out of his monthly opioid allotment, he has to make hard decisions on who gets their medications.

Mukash Patel, owner of pharmacies in Dix Hills and Patchogue, said he sometimes can’t get certain opioids “for days on end.”

“The patient should not have to run around calling 30 different places to see if the drug is in stock,” he said.

Often, pharmacies won’t tell patients if they have a medicine, so Rubin said his staff must make the calls.

“We don’t have the bandwidth to be calling a dozen pharmacies for everybody who can’t get their medication,” he said.

Lauren Esposito, spokesperson for one of the distributors in the opioid settlement, Pennsylvania-based Amerisource Bergen, said in a statement that distributors “have been asked to walk a legal and ethical tightrope by both maintaining access to products while simultaneously limiting potential diversion.”

She called for better federal guidance “to support patient access.”

State opioid tax

D’Angelo said a state excise tax on most opioids, approved by the New York Legislature in 2019 as part of the state budget, aggravates the problem.

Wisconsin-based Independent Pharmacy Cooperative stopped selling opioids in New York that were covered by the excise tax before it went into effect because “we thought that continuing to sell would likely mean that it would have been unprofitable,” said the company’s general counsel, Paul Karch. Last year, the company stopped selling all opioids nationwide because of high monitoring costs, he said.

Assemb. Linda Rosenthal (D-Manhattan), who headed the Assembly’s alcoholism and drug abuse committee when the tax was enacted, opposes the way the tax is structured because it can lead to higher prices for consumers, as well as lower supply. She called on the Department of Health to study the problem and find solutions.

Dr. Thomas Jan, a Massapequa pain management and addiction physician, said pain patients shouldn’t have such difficulty obtaining prescribed medications. But, he said, in the past, many well-intentioned doctors were too quick to prescribe opioids, and they often prescribed too much, putting patients at increased risk of addiction. Jan said around 2010, his then-16-year-old son was prescribed 90 Vicodin pills after having a wisdom tooth pulled.

Dr. Yili Huang, a regional manager for pain management services for Northwell Health, said additional controls have caused doctors to think more carefully about alternatives to opioids. But opioids still have an important role, especially in relieving pain after surgery and for cancer, palliative and end-of-life care, he said.

Yet some doctors are hesitant to prescribe opioids, for fear of being “stigmatized as a doctor that prescribes a lot of opioids,” Huang said.

Rubin said he is conscious of the risk of developing dependence or addiction to opioids, so about nine in 10 of his new patients “probably will never see an opioid.”

“We have more options than we ever had to treat patients with injections and those types of therapies,” he said.

Rubin most often writes opioid prescriptions for patients in severe pain after major surgery. For chronic pain patients who previously weren’t prescribed opioids, “We’re really trying to save it as a last resort,” he said.

The CDC’s 2022 guidance for opioid prescribing says there is insufficient evidence to determine the long-term benefits of opioid therapy for chronic pain. But, the CDC said, doctors should carefully weigh the risks and benefits of discontinuing opioids for those already prescribed them.

Rubin is reluctant to take chronic pain patients off opioids if the medication has been helping them long term.

“There are lawyers and accountants and people like that who couldn’t sit in a chair all day and work at their desk without their pain medicine,” he said. “Society has to separate those people who are using medication judiciously and not lump them in with people who are trying to take high doses in an abuse-type situation to get high.”