Opinion: Once Again Congress Practices “Burn Before Reading”

By Richard A Lawhern, PhD.

News from last week highlights President Trump signing into law, the “Veterans Administration Mission Act”.  Much is being made of the provisions of this Act which allow veterans to seek insured medical care outside of Veterans Health Administration hospitals.  But most reporters have missed a “poison pill” in the legislation that places the lives of thousands of veterans at risk.

Section 131 of the Act reads as follows:

Section 131 would ensure that contracted providers have reviewed the evidence-based guidelines for prescribing opioids set forth in the Opioid Safety Initiative before providing care through the community care program. This section would also require VA to implement a process to make certain that community care providers have access to available and relevant medical history of the patient, including a list of all medication prescribed to the veteran as known by VA.

This section would require that contracted providers submit medical records of any care or services furnished, including records of any prescriptions for opioids, to VA in a time frame and format specified by VA. VA would be responsible for the recording those prescriptions in the electronic health record and enable other monitoring of the prescription as outlined in the Opioid Safety Initiative.

This section would require a report each year evaluating the compliance of contracted providers with the requirements of this subsection. If VA determines that a community provider is not complying with the Opioid Safety Initiative, VA is authorized to refuse authorization of care by such provider and direct their removal from the community care network.

Richard “Red” Lawhern

It all sounds pretty innocent, doesn’t it?  But it’s not.  The so-called Safety Initiative is anything but safe.  It is a prescription for medical disaster.

The Initiative is built around a 191-page monster Clinical Practice Guideline [https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf]  with four complex and confusing flow charts that physicians must implement.  But there is a bottom line in this confusion.  Even if non-opioid therapy has been ineffective in managing pain, VA doctors must now “manage with non-opioid modalities”.  Legacy patients long treated with high-dose opioids must be tapered to below 90 Morphine Milligram Equivalent per day – even if assessed risks of opioids are outweighed by benefits.  And any doctor in private practice who treats veterans must do the same.

Ninety MME is the magical mystery number invented out of thin air and unsupported opinion by writers of the 2016 CDC Guidelines.  CDC publicly proclaims that their guideline was intended to be voluntary for General Practitioners.   But patients know it is not.  CDC Guidelines have caused tens of thousands, many of them veterans, to be deserted by their doctors or forced into coerced tapering of medications to below useful levels.   Possibly hundreds have committed suicide to escape overwhelming agony.  The Veterans Administration Mission Act has doubled down on the carnage.

Congress has once again passed healthcare legislation that it doesn’t understand and cannot possibly have read in detail.  Pain management specialists know that the optimum therapeutic dose range for opioid pain relievers is about 50-1000 MME per day – far exceeding CDC limits.  Opioid dependence can occur when opioids are used for long periods.  But the Director of the National Institute on Drug Abuse informs us that dependence is not addiction.  Addiction is rare in pain patients [https://www.nejm.org/doi/full/10.1056/NEJMra1507771], despite the ignorant hype spread by hysterical anti-opioid zealots and ill informed reporters.

It is time to repeal Section 131 of the VA Mission Act and revise VA Practice Guidelines.  Call your legislators and tell them so.

Richard “Red” Lawhern Ph.D. is Co-Founder and Corresponding Secretary of the Alliance for the Treatment of Intractable Pain

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