Crackdown on opioids takes toll on Hawaii patients

Nov. 26--Lance Machamer has Purple Hearts for combat wounds from a grenade that exploded around him in the Vietnam War.

He also has shrapnel fragments from the grenade still lodged in his neck and temple that cause excruciating pain when his medications are not just the right dose.

"I describe it as a little man standing behind me with an ice pick shoving it up my neck and into my brain. That's about what it feels like," said Machamer, who was just 19 years old when he was severely injured.

Machamer has found himself in the crosshairs of a nationwide effort to reduce prescription opioids as health officials seek to curb drug overdoses, the leading cause of injury-related deaths in Hawaii. The national crackdown on opioids is taking a huge toll on some of Hawaii's chronically ill patients who are unable to fill their medications to control their pain.

"Because of this opioid epidemic thing, everybody's all of a sudden seeing boogeymen everywhere, and every veteran's a junkie, though I never felt that I had a high off anything in the 50 years. I'm just happy when I can take the edge off," said Machamer, 70, who also suffers from a neuromuscular disease and regularly takes hydromorphone, one of the strongest and most addictive opioid drugs. "I don't take these things recreationally. I take them to survive."

Machamer, who takes 8 milligrams every four hours, is an outlier in that he needs more than the normal person to treat the pain he's had for the past 50 years. Now the Veterans Administration pharmacy is trying to negotiate lower dosages with his doctor, but it is not effective enough to curb his pain.

"It's not a negotiation because they don't leave me any option. In a sense they're telling me how to prescribe for this guy. My patients are suffering," said his doctor, Patricia Borman, a family medicine practitioner since 1986 who specializes in geriatrics and pain management. "I get so angry that my patients and I are made to feel like criminals to obtain these important medications. The real patients who need the correctly dosed opioid prescriptions are now stuck in the crosshairs of a cultural divide."

Borman, who has prescribed opioids for years, also knows what it's like to not be able to get them for her own pain. She said she recently had kidney stones, and a pharmacy refused to fill her oxycodone prescription on a Saturday due to a new opioid policy. The pharmacy first had to contact her prescribing physician to review her treatment plan and verify the prescription was for a legitimate problem and that nonopioid alternatives had been considered.

"It was Tuesday before I could get any medicine. The pain is now," she said. "People are bringing legal, legitimate prescriptions to the pharmacy and just facing what seems like insurmountable barriers."

Opioid prescriptions in Hawaii have decreased significantly in recent years. There were roughly 717,000 prescriptions in 2014, compared with 646,000 in 2015, a decrease of about 71,000, according to the latest data from the Centers for Disease Control and Prevention. Meanwhile the state reported 49 opioid-related deaths due to overdoses in 2017, down from 74 in 2016, state Health Department statistics show, following new guidelines by the CDC that placed limitations on prescription opioids.

"We definitely don't want to keep people from palliative pain medications," said Eddie Mersereau, chief of the state Health Department's Alcohol and Drug Abuse Division and a member of Gov. David Ige's task force to combat opioid abuse. "There's no reason why people who need pain medications should not be able to get them."

Honolulu pain specialist Dr. Jeffrey Wang said he receives complaints daily from patients unable to fill their prescriptions.

"The problem of legitimate patients not being able to get their medications is getting worse," he said. "The problem is that the (Drug Enforcement Administration) has told the manufacturers to manufacture less so that there will be less for diversion. If you don't have enough supply and your demand is still there, pharmacies can't hold medications waiting for cancer patients to come in. If you're at the end of the pharmacies supply before their next order comes in, then you're out of luck."

Hawaii law limits chronic-pain patients to a 30-days-at-a-time prescription, while guidelines by the CDC for primary care physicians limit the dosage to no more than 90 morphine milligram equivalents. Some doctors say they no longer have the power to prescribe what patients need because insurance companies and pharmacies, citing the guidelines, restrict the practice of medicine. The CDC guidelines also discourage mixing narcotics with benzodiazepines (tranquilizers), sleep aids or muscle relaxants, while state law limits initial opioid prescriptions and benzodiazepines to seven days.

"The use of narcotics in the pain management field has come down. We are looking at other techniques. Narcotics is not our first-line go-to treatment," Wang said. "But there are some people who require its use. I believe it can be done safely if done appropriately."

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