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Christie set to impose pain pill limits despite N.J. doctors' objections

TRENTON - Gov. Christie wants to tackle opioid addiction by limiting the number of pills physicians can initially prescribe - an idea experts say could reduce excess supply but may cause some pain patients to go days without medication.

TRENTON - Gov. Christie wants to tackle opioid addiction by limiting the number of pills physicians can initially prescribe - an idea experts say could reduce excess supply but may cause some pain patients to go days without medication.

Christie, a Republican serving the last year of his second term, last week ordered new rules that would limit doctors to writing initial prescriptions for five days' worth of opioid-based medications, down from 30.

The regulation would apply to patients with acute pain, such as a broken wrist, not those with chronic pain. Following a consultation, either by phone or in person, doctors could prescribe more opioids, such as oxycodone and fentanyl, to acute-care patients.

"It is my expectation that this will substantially reduce the risk of addiction and the accumulation of opioids in household medicine cabinets across the state, stockpiles that are ripe for diversion," state Attorney General Christopher Porrino wrote Wednesday in a letter to the State Board of Medical Examiners, according to a copy provided to the Inquirer.

New Jersey's physicians lobby denounced the proposal, first announced by Christie during his annual State of the State address Jan. 10, as an "intrusion into the practice of medicine" that would reduce quality of care.

But some researchers on the opioid epidemic say Christie's proposal a step in the right direction.

"It's a smart move. These types of limits are being increasingly applied around the country," said Dr. Caleb Alexander, codirector of the Johns Hopkins Center for Drug Safety and Effectiveness. "To a large degree opioid accidents and injuries and deaths are driven by the incredible volume of opioids on the market."

Dr. Jeanmarie Perrone, a professor of emergency medicine in the Perelman School of Medicine at the University of Pennsylvania, said, "Liberalizing the threshold for initiating opioids I think has really been the crux of how we've gone wrong."

Alternative therapies - including everything from muscle relaxants to meditation - should be considered for pain management, experts said.

Health-care providers wrote 259 million prescriptions for opioid pain medications in 2012, according to the federal Centers for Disease Control and Prevention, or enough for a bottle of pills for every adult in America.

U.S. drug deaths soared to a record high of more than 50,000 in 2015. The rate of fatal overdoses in New Jersey surpassed the national average, and Pennsylvania's rose twice as fast. More than 60 percent of drug deaths involve an opioid, according to the CDC.

Heroin deaths were up 30 percent in the Garden State, Christie said, and the number of deaths caused by the opioid fentanyl tripled.

Porrino will use emergency rule-making powers to implement Christie's proposal as early as Feb. 17, a spokesman for the attorney general said.

Failure to comply could result in suspension of medical licenses and disciplinary sanctions. The regulation also will require doctors registered to prescribe controlled dangerous substances to take continuing education coursework on opioids.

The rules are being drafted in accordance with federal guidelines, Porrino wrote, following states that have implemented similar measures, such as Maine, New York, Massachusetts, and Connecticut.

As part of his anti-addiction agenda, Christie wants to prohibit insurers from denying coverage to citizens with health insurance for the first six months of inpatient or outpatient drug rehabilitation treatment; expand access to sober living homes; and develop school curriculum on opioids.

But it is his proposal to scale back prescriptions that has New Jersey's medical organizations scrambling.

"I do think there needs to be a limit. But once you start setting a rigid, somewhat arbitrary determination of what that limit is, you run into trouble," said Michael W. Shore, a Cherry Hill psychiatrist and president of the New Jersey Society of Addiction Medicine. "There's always going to be exceptions."

Shore suggested a 15-day initial prescription limit would be a reasonable compromise to provide for more flexibility.

But he and others noted that scheduling a follow-up appointment with a doctor after receiving an initial five-day prescription could result in delays in treatment for pain patients.

It's also not clear what would count as five days' worth of medication: How many pills and at what dose?

"Having people be reassessed frequently is not very feasible, unfortunately," said Perrone, the Penn doctor who works in an emergency room. It's "really challenging to make rules that should apply to everyone. I think that's why we need a global education about it. Family members should understand the dangers of these drugs."

Patients and their families naturally want the strongest drug to reduce pain, but taking opioids at the acute stage risks a long-term dependency, and the pain may not even subside, Perrone said.

"We need to change the paradigm," she said. "You don't want someone to start opioids for a finger fracture."

A key question is whether imposing pill limits could have the unintended consequence of boosting heroin use, as the physicians lobby argues.

The idea is that because prescription opioids and heroin are pharmacologically similar and can produce similar highs, limiting the availability of one drug will increase demand for the other.

Some research suggests that correlation is misleading.

For example, a comprehensive review last year in the New England Journal of Medicine concluded that heroin use began to rise before "policy-driven reductions" in the availability of prescription opioids were "robustly implemented," making "a causal link unlikely."

Rather, the report found, increased rates of heroin use were likely driven by its cheap cost and accessibility.

Alexander, the Johns Hopkins expert, said reducing prescription opioids "and expanding treatment capacity for heroin are not mutually exclusive."

Mishael Azam, senior manager for legislative affairs for the Medical Society of New Jersey, said that instead of imposing new prescription mandates, the state should see whether other recently enacted laws are effective in combating the epidemic.

One law, passed in 2015, requires pharmacies and prescribers to educate patients how to properly store and dispose of unused prescription drugs. "That could really nip the problem in the bud if people are much more conscious about counting their pills" and ensure others don't use them, Azam said.

She noted that of the people who misuse prescription painkillers, only about 20 percent received them from a doctor. Christie's plan punishes the vast majority who use opioids responsibly, she said.

Alexander said that missed the point.

Half of those who abuse the drugs report getting them from a friend or relative, according to 2013-14 National Survey on Drug Use and Health.

"Many prescriptions may be written for clinically appropriate purposes and still inadvertently contribute to the epidemic because they go unused and ultimately are given or sold to friends or family members," he said.