PHARMACIST STEVE

lynnwebstermd.com
When Will Forced Tapering of Opioids End?
Lynn Webster, M.D.
6-8 minutes
When Will Forced Tapering of Opioids End?

20th April, 2019

By Lynn Webster, M.D.

This article, in a slightly edited form, first appeared on Pain News Network on April 17, 2019.

“Larry” recently wrote to me asking for advice. He describes himself as “virtually crippled totally” after having his opioid medication cutback.

“I am being forced tapered and the PA I now have will not budge one inch on the weaning, as he calls it. I hate him. I have never had a more callous doctor in my life,” Larry wrote.

“What does one do in my situation? Blow my brains out? A[n] intentional overdose? I have two beautiful dogs that depend on me and a son who needs me. I have to stay here on planet Earth although I want out of here so bad I beg God to kill me every morning noon and night. It is my daily prayer.”

Unfortunately, Larry is only one of many patients who are struggling to be heard by their providers. Physicians are under government pressure to adhere to the CDC’s 2016 opioid prescribing guideline.

Although the CDC designed its guideline as voluntary, government agencies interpreted it as a mandate instead. The Drug Enforcement Administration has pursued doctors who prescribe a level of opioids that exceeds the guideline’s recommended daily limit of 90 MME (morphine milligram equivalent), even when no patients have been harmed.

According to Maia Szalavitz, writing for Tonic, Dr. Forest Tennant was one of the few physicians who still were willing to prescribe high-dose opioids for the sickest pain patients. The DEA raided his California office and home, allegedly because the agency had reason to believe some of his patients were selling their medication.

There simply was no evidence of that. But as a result of the raid, Dr. Tennant retired from clinical practice.

Szalavitz wrote that the raid “terrifies pain patients and their physicians, who fear that it could lead to de facto prohibition of opioid prescribing for chronic pain and even hamper end-of-life care.”

Dr. Mark Ibsen in Montana had his license suspended by the state medical board for allegedly overprescribing opioids. According to Dr. Ibsen, the DEA warned him “he was risking his livelihood and could end up in jail if he kept prescribing.” A judge later overturned the board’s decision.

As Dr. James Patrick Murphy, a Kentucky-based pain and addiction specialist, told the Courier-Journal, “many well-intended doctors are unfairly arrested ‘all the time’ in the hunt for those who recklessly contribute to patients’ addictions and fatal overdoses.”

As of this writing, The American University Law Journal plans to publish an alarming article by Michael Barnes, JD, about the raids on America’s top physicians.

Although few physicians are incarcerated for prescribing high dosages of opioids, many of them are threatened with losing their licenses to practice medicine. Doctors and pharmacists told a POLITICO survey that they felt enormous pressure to limit their prescriptions for painkillers. Their fear of the consequences of noncompliance with the CDC guideline exceeded their responsibility to treat patients with severe pain.
Second Thoughts About CDC Guideline

On April 1, the attorneys general of 39 states and territories wrote a letter on behalf of the National Association of Attorneys General to Dr. Vanila Singh of the U.S. Department of Health and Human Services. The letter expressed concern with the draft report of the Pain Management Best Practices Inter-Agency Task Force, which recommends changes in the CDC guideline to end the forced tapering of patients.

The attorneys general said “it is incomprehensible that officials would consider moving away from key components of the CDC guideline.” Additionally, they expressed their hope that the report would be revised “to clearly state that there is no completely safe opioid dose.”

Yet on April 9, the Food and Drug Administration issued a medical alert warning doctors not to abruptly discontinue or rapidly taper patients on opioid medication, because it was causing “serious harm” to patients, including uncontrolled pain, psychological distress and suicides.

Now it seems the CDC may be moving in the same direction.

Dr. Daniel Alford, a Professor of Medicine at Boston University, wrote a letter to the CDC asking it to address the misapplication of its guideline with a “public clarification.” He was writing on behalf of Health Professionals for Patients in Pain, and 300 healthcare professionals signed his letter.

The CDC’s response, published on April 10, echoed the FDA’s statement. CDC Director Dr. Robert Redfield observed that the CDC guideline “offered no support for mandatory opioid dose reductions in patients with long-term pain.” He reinforced the fact that the guideline was voluntary and that doctors should use their knowledge of their patients to determine which dosages were appropriate for them.

Dr. Redfield wrote that “CDC is working diligently to evaluate the impact of the Guideline and clarify its recommendations to help reduce unintended harms.” And he agreed that “patients suffering from chronic pain deserve safe and effective pain management.”

STAT News points out that the overzealous enforcement of the CDC guideline was indeed causing patients harm. “Denying opioids to patients who have relied on them — sometimes for years — may cause some to turn to street drugs, thereby increasing their risk of overdose,” STAT warned.

According to The Washington Post, “Many patients have claimed that long-term use of the drugs is all that stands between them and unrelenting pain, and that they can take the medication without becoming dependent or addicted.”

The CDC and the FDA now admit the guideline has been misapplied and mainstream media outlets are beginning to pick up the story. The question is: Will the DEA stop pursuing doctors who treat pain patients with levels of opioids that exceed the guideline’s recommendations?

For Larry and other pain patients who have been forcibly tapered, the answer may be a matter of life and death.

http://www.lynnwebstermd.com/forced-tapering/

Here is four quotes from the CDC opiates guidelines:

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function.”

“Clinicians should consider the circumstances and unique needs of each patient when providing care.”

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”

The entire CDC guidelines are some 90 odd pages.   What “key components” of the CDC guidelines are they focused on 90 MME ? – out of 90+ pages.  I particularly like this quote from these 39 “medical experts”  to clearly state that there is no completely safe opioid dose… there is no really “safe dose” of ANY MEDICATION… they are trying to force our body to do something that it naturally wants to do.

The CDC guidelines completely ignores the fact that we have a test .. CYP-450 opiate metabolism test – a simple cheek swab – that will determine if a pt is slow, normal, fast, ultra fast metabolizer and the pt’s dose may have to be increased and/or frequency of the dose increased and/or BOTH !

These same guidelines IGNORE that all of the opiate conversion programs have a footnote stating – the same or similar – that the results of using these conversion programs – ARE CRUDE ESTIMATES AT BEST and should not be used as black/white pt dosing .. only as a starting point.

Some of us believe that the CDC did not have the statutory authority to even generate and publish these guidelines.  Maybe that is why the then head of the CDC Tom Frieden shortly after they were released made a public statement that these guidelines were just RECOMMENDATION and DID NOT HAVE THE AUTHORITY/WEIGHT OF LAW.  Could that have been a “back door” admission that the CDC did not have the legal authority to publish these guidelines ?  After all the CDC’s primary charge is dealing with contagious diseases.

But then when you assembly a committee to develop these guidelines that each has a personal interest in treating substance abusers, what would one expect but a final product that primarily deals with .  It also seems suspicious that this committee met behind closed doors and the CDC tried to keep the committee members anonymous .

So in the end we have 39 state AG’s who wish to continue honoring “guidelines” as LAW that were created by a Fed agency that may not have had the statutory authority to generate them in the first place and they may well be unconstitutional. 

Also it seems to be a quote from these AG’s “it is incomprehensible that officials would consider moving away from key components of the CDC guideline”.. so it would appear that these AG’s prefer to only chose a favorite sentence, paragraph or page out of the 90+ page document to be the “key components” that they wish to have adhered to.

It would not be the first time that a legislative body will have passed a bill that gets signed into law and remains on the books and is enforced until someone challenges the constitutionality of the law in the courts.  In our legislative system, there is no process to validate the constitutionality of a bill before it gets signed into law.

Filed under: General Problems