Recently I met with a woman, a casualty of our nation’s clumsy efforts to curb its opioid crisis. Her story shows how a myopic fascination with numeric targets, which caused so much harm as our prescribing went up, is likely to cause just as much harm as it comes back down.
A 60 year-old kidney transplant recipient, she required a slew of medications to protect her transplanted kidney. She also took over 100 milligrams daily of an opioid for painful arthritis. Amid national calls to reduce opioid prescriptions, one doctor after another lowered her doses in simple 50 percent steps.
None of them documented any problem caused by her pain pills. None sought her consent. Predictably, she fell apart, as did her adherence to other medications, including ones to protect her kidney. Life spiraled out of control. Ultimately, the threat of losing her kidney compounded the uncontrolled pain of her arthritis. Whether she will keep her costly transplant, or go back on dialysis, is not yet known.
Clumsy new opioid policies are practically designed to ensure her story is not unique. The pressure on physicians is already intense. It comes from legislators, law enforcement, insurers, and leaders who equate prescribed opioids with illicit heroin.
Accordingly, doctors cut doses unilaterally and shun pain patients. Last month, two national agencies entered the fray, with the National Committee for Quality Assurance and the Centers for Medicare and Medicaid Services proposing escalate the pressure. One (CMS), will restrict insurance coverage based on dose. The other (NCQA), proposed a quality measure to flag physicians as engaged in bad practice if they let doses remain high, regardless of how well or poorly the patient is doing.
It will surprise many to learn that such plans were not endorsed by the Centers for Disease Control and Prevention (CDC) in 2016, whose review found no data to support the unilateral dose reductions that CMS and NCQA will incentivize.
In its 7th recommendation, the CDC urged that care of patients already receiving opioids be based not on the number of milligrams, but on the balance of risks and benefits for that patient. That two major agencies have chosen to defy the CDC ignores lessons we should have learned from prior episodes in American medicine, where the appeal of management by easy numbers overwhelmed patient-centered considerations.
In years past, we erred when observational data led agencies such as NCQA to demand strict control of blood sugar in all diabetes patients. Subsequent trials showed that harmed many patients, and helped only some. Similarly, millions of postmenopausal women were thrown onto estrogen because observational data suggested it prevented heart attacks. Later trials showed we were causing heart attacks, not preventing them.
Even the run-up in opioid prescribing emerged from an unhealthy enchantment with a single number, the pain score, at the expense of common sense. The cardinal lesson is this: prior to imposing simple numeric targets on all patients, we should require prospective trials showing benefit. That’s what we lack for unilateral opioid dose reductions.
As physicians today execute a hard shift on opioids, I plead for caution. Patients with chronic pain report enormous suffering, some committing suicide as they see their lives turned upside down by doctors pressured to reduce.
A rising tide of concern has emerged among academic physicians who have dedicated their work to fighting addiction, including some who worked on the CDC Guideline itself. They see that clinical practice has sprung ahead of data, that it has begun to look like someone has shouted fire in a crowded theater, creating a social stampede. This does not reflect the cautious, patient-centered care urged by the CDC.
To be sure, unrestrained opioid prescriptions are dangerous. A run-up in prescribing from 2000 through 2011 fueled a spread of addiction and overdose, sometimes to pills we prescribed, and often to opioids illicitly distributed. In 2015, 33,091 Americans died from overdose. The percentage of patients prescribed an opioid who develop addiction is hard to pin down, but the CDC estimates 0.7 percent (at lower doses) to 6.1 percent (at higher doses).
Without oversight and guidelines urging caution, more will be harmed. However, this prudent check on uncontrolled prescriptions need not create a whole new population of chronic pain patients who suffer from overly-prescriptive and oversimplified recommendations that force all prescriptions below a uniform milligram limit.
Eighty professionals, including four who worked on the CDC Guideline, signed a public letter to NCQA, raising the alarm about this entirely predictable downside of new dose-curtailing policies, as did 83 who signed a letter to CMS a few weeks ago.
Among them were leading scholars in addiction medicine, pain and health care quality improvement. We can listen to these experts, or we can let more patients suffer. Now is a good time to remember how easy numbers sometimes make for bad care.
Stefan G Kertesz, MD, is a physician in internal medicine and addiction medicine on faculty at the University of Alabama at Birmingham School of Medicine. Views expressed are his own and do not represent formal positions held by any of his employers. Follow @StefanKertesz.
Filed under: General Problems
Leave a Reply