Painkiller Directive Latest Way to Avoid Opioids

The ease of relapsing into opioid addiction has led a growing number of states to help residents make it clear to medical professionals they do not want to be prescribed the powerful painkillers.

Connecticut and Alaska are two of the latest considering legislation this year that would create a “non-opioid directive” patients can put in their medical files, formally notifying health care professionals they do not want to be prescribed or administered opioid medications.

Legislators in Massachusetts and Pennsylvania last year voted to create similar voluntary directives.

While patients typically have the right to make decisions about the medical care they receive and whether they want certain treatments, proponents of non-opioid directives contend such a document make a patient’s wishes clear, especially in advance of medical care or if a patient becomes incapacitated. They are also seen as a way to prevent someone in addiction recovery from relapsing. The National Institute on Drug Abuse notes how exposure to drugs is one of the most common triggers for relapse.

“Whether it’s in some type of directive in a treatment plan, we have a right to choose what we want in our care,” said Kelvin Young, who is recovering from opioid and heroin addiction and is now director of Toivo, an alternative drug rehabilitation program in Hartford.

Such directives, however, are not a one-size-fits-all solution.

Seth Mnookin, an assistant professor at the Massachusetts Institute of Technology graduate program in science writing, acknowledged they’re “not the most nuanced approach to the problem.” He has written about taking opioids almost two years ago for kidney stones and a related infection, even though he previously kicked a three-year heroin addiction in 1997.

“There was no question that I needed powerful pain medication. Having a no-opioids directive in that case probably would have created a whole bunch of problems,” said Mnookin, who said it felt like his “gut was being hacked at with a phalanx of rusty chisels.”

During his hospital stay, Mnookin said, he repeatedly told doctors about his substance use disorder. However, he felt they weren’t listening. Ultimately, he did not receive any counseling or advice regarding the risk of a potential relapse or how to guard against one. He wound up creating his own chart to ensure he didn’t take too many pills.

“That’s not something I think everyone is going to do,” he said.

Mnookin said states should consider requiring patients with substance abuse histories to see an addiction specialist after receiving pain medication to prevent a relapse.

“In my case, I would not have written a directive,” he said. “But, the fact that this legislation is being introduced means there’s awareness of the necessity of having more conversations, having people outside of an addiction specialist being aware of people’s histories.”

Sue Kruczek, of Guilford, Connecticut, has worked to pass opioid legislation since her 20-year-old son Nick died in 2013 of a heroin overdose following an addiction to prescription drugs.

“It seems like the hospitals are unaware of the history,” she said.

In Massachusetts, a patient, or the patient’s guardian or health care agent, signs a one-page form that states: “I am refusing at my own insistence the offer or administration of any opioid medications including in an emergency situation where I am unable to speak for myself.” The person also agrees they understand the risks of refusing and release the health care professionals “from any responsibility for all consequences.”

The directive, which must also be signed by the health care practitioner, became available in January. The Pennsylvania directive is still being developed.

Pennsylvania state Rep. Ed Gainey, a Democrat, proposed the directive legislation. Representing a section of Allegheny County that’s seen hundreds of opioid overdose deaths over the past two years, Gainey said he sees the directive as a patients’ rights issue, an opportunity to empower people who may fear relapsing into addiction, but also becoming addicted.

“My whole thing is, `how can we give patients more control over their destiny?”‘ he said. “A lot of people are more aware now and while they’re more aware, it’s good that we let them know they have an option to opt out and not receive prescription drugs.”