On March 15, 2016, the Centers for Disease Control and Prevention (CDC) published its Guideline for Prescribing Opioids for Chronic Pain. The recommendations were designed for primary care clinicians who are prescribing opioids for chronic noncancer pain. Its purpose was to lower the supply of prescription drugs and decrease the number of opioid overdoses.
Pain advocacy groups were concerned that the CDC Guideline for Prescribing Opioids for Chronic Pain could have unintended negative consequences when they were introduced. For example, the Cancer Action Network‘s president, Chris Hansen, published a statement called “Final CDC Opioid Prescribing Guideline Could Have Unintended Consequences for Cancer Survivors Living with Chronic Pain.” It read, in part, “We are disappointed that the CDC guideline released today did not address our previously stated concern about needed access to opioid analgesics for cancer survivors who experience severe pain that limits their quality of life.”
The CDC positioned the guideline as voluntary. But, five months after the guideline was published, the CDC was cautioned by a public relations firm they hired, “Some doctors are following these guidelines as strict law rather than recommendation, and these physicians have completely stopped prescribing opioids.” The CDC ignored the warning.
Even worse, last month, the Oregon Health Authority proposed denying access to opioids for most people with chronic non-cancer pain. The Oregon Health Authority has lost sight of the fact that the amount of opioids prescribed is only one factor — and may not be the primary factor — contributing to the opioid crisis. Lack of access to adequate mental health and addiction treatment has also contributed to the problem.
Oregon is not the only state that is limiting access to opioids. Michigan, Florida, and Tennessee are among other states that have also passed laws restricting physicians’ ability to prescribe opioids. Utah-based Intermountain Healthcare has implemented forced tapering to achieve their goals of lowering prescriptions by 40 percent in 2018. In other states, health-care plans and insurers, such as Cigna and Aetna, have similar goals.
The assumption that denying prescription opioids to those in severe pain regardless of the diagnosis will stop abuse is foolhardy and harmful. As states and insurance companies begin to implement similar restrictive prescribing policies for the treatment of chronic pain, we will see at least two negative effects:
First, people with a substance abuse disorder (SUD) who are using prescribed opioids for the wrong reasons are not going to suddenly stop using drugs because they aren’t readily available. Instead, they will seek other sources of drugs. They will turn to the streets for their opioid replacements. This may contribute to more deaths, because the streets are where the most dangerous drugs are found.
This is illustrated by what occurred when the abuse-deterrent OxyContin was introduced. Abusers began substituting heroin when OxyContin became more difficult to obtain and abuse. The National Bureau of Economic Research’s published 2017 report, “Supply-side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids,” explains how supply-side strategies alone are inadequate for dealing with drug abuse.
Second, people in pain who have been functioning on their medication without signs of abuse may be at an increased risk for suicide. Without adequate pain treatment, they may lose significant quality of life. In some instances, people will feel abandoned and hopeless.
It is not an exaggeration to suggest that some people in severe pain who are denied access to opioids will view suicide as the only way to escape their severe pain. Inadequately treated pain is a risk factor for overdoses and suicides. Recent research suggests as many as 30 percent of unintentional opioid-related overdose deaths may be suicides.
Certainly, opioid abuse is a significant problem and must be addressed. But policies to force opioid tapering as a way to mitigate the opioid crisis are ill-conceived. To set arbitrary dose limits without consideration of patients’ needs is malevolent.
The CDC needs to respond to the unintended harm the guideline has created. They should follow the lead of Canadian physicians. The College of Physicians and Surgeons of British Columbia (CPSBC) revised the guidelines that they adopted from the CDC following consultation with physicians in the Province and patients who were being denied care, abandoned, or forced to decrease doses to 90 mg morphine milligram equivalents (MME) or less suggested by the CDC guideline.
By contrast with the CDC, the CPSBC recognized the harm that the guidelines were producing for some patients, and they had the courage and leadership to clarify their previous recommendations. They announced, “Physicians cannot exclude or dismiss patients from their practice because they have used or are currently using opioids. It’s really a violation of the human rights code and it’s certainly discrimination and that’s not acceptable or ethical practice.”
The nonprofit New York-based Human Rights Watch (HRW) organization that typically tracks and exposes war crimes apparently agrees with the CPSBC, because they recently expressed concern about the CDC guidelines’ potential consequences for pain patients. HRW is investigating whether people’s right to receive appropriate health care when they are in pain has been violated if they have been forced to reduce their medication. They expect to produce a report later this year.
It is important to find answers to the drug crisis, but the solutions must not create more harm than benefit to both people in pain and people with addictions. The current implementation of the CDC’s Guideline for Prescribing Opioids for chronic pain does not achieve this end and is not patient-centered. Hopefully, the CDC will assume the responsibility to clearly state their guideline is not being implemented as they intended.
The CDC should issue a public statement similar to the one published by the CPSBC clarifying that physicians should not dismiss patients or deny them access to pain care because they are on opioids, even if the dose they need is above 90 mg MME. This is not advocating for opioids but, rather, advocating for patients. It respects the human right to receive compassionate care.
Lynn R. Webster, MD is a vice president of scientific affairs for PRA Health Sciences and consults with Pharma. He is a former president of the American Academy of Pain Medicine. Webster is the author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” You can find him on Twitter: @LynnRWebsterMD.
Filed under: General Problems
To who ever it concerns thank you so much. please feel free to publicly post and use this my story and grief of this horrible malady and the the Hell the now uninformed Public and some of the Media are putting us legitimate Chronic Pain Sufferers through! It is no more than local emotional Abuse ( and border line Domestic Emotional Terrorism )!on a scale with only Biblical proportions!To the Editor and Associates I have taken this opportunity to share my heartbreaking story in hopes these witch hunting Opiate ill informed skeptics will read and understand that we as Millions Of Legitimate Chronic Pain Sufferers would have no life without Medically prescribed Opiates by a physicians care and strictly monitored monthly urine and blood test. Please remember that An Opinion Before A Thorough Investigation Is The Epitome Of Ignorance! And that a little more compassion from the Medical Field and its representatives could have saved my beautiful Stepdaughters life. Let me say this! A person who has a addictive personality will abuse anything that helps them feel better. I have taken Oxycontin for 12 years , I have had 20 major surgery’s in 9 years. I have so much physical pain I can not even get out of bed with out pain meds and when I run out I run out and just lay in bed praying the Lord relieve me of this horrible condition and I pray God you pain med skeptics never go through what I go through everyday of my life when the only thing you have to do is threaten what help I get, Shame on them! There will always be drug abuse and as the so called war on drugs has failed all this will! All you do is stoke and aid the drug pushers business to knew heights in the Black Market of Heroin while trying to deprive folks as me to this horrible movement! My Stepdaughter committed suicide 4 years ago because of being treated like a drug addict by her family and doctors when all along she suffered from Lupus and Fibromyalgia which I believe was brought on by a deadly car crash at 18 , she told me between that which I was being put through and what they were putting her through she was not going to be able to live her life in such a hell brought on by people like the Biased Uniformed Skeptics that are on a witch hunt to out law Opiates and pain meds that give us some sort of a life . As a retired Police officer and worked indirectly close to the DEA, you people do not have a clue how thrilled you are making the illegal opiate trade and think of my Late Stepdaughter as you continue on with this 2017 Version of the ( 1940s Propaganda Film named REEFER MADNESS )movement to outlaw opiates! Just like the slaughter of children at Sandy Hook if there would have just been gun laws , my God they were Gun Laws , the guns that murdered all those 20 children were all registered and owned by a school teacher! You fight Drug Addiction in Elementary education by teaching all children the dangers of Booze and Tobacco which if these witch hunters want for us to know the real truth but they do not. I miss my Stepdaughter so much and some of us will continue on the fight to protect our right to feel better and function without fear of these witch hunters trying to convince us to commit suicide . And they are trying to do exactly THAT and are now being successful in this under the table practice of Human Genocide!
The under line real truth it seems THESE witch hunters would rather us Chronic Pain sufferers commit suicide are and DRINK all the BOOZE we can drink! The Federals legalized it ( ALCOHOL) knowing its a more deadly drug than Strychnine. And just because the DEA has miserably failed with their witch hunt type movement on drugs why do they continuous fully deprive us sick people of our Constitutional Rights to be Happy in that pursuit of with Professional Physicians to take meds that give us relief of this horrible malady of Chronic Pain ! May God have mercy on their miserable souls they that seek to destroy us Chronic Pain Sufferers only and little hope of temporary relief of this horrible sickness.
Well I had a long post written about my own experience with almost being labeled as having OUD, due to under treatment of pain, but I hit the wrong button and it’s gone now. Anyway, all I really meant to say was that the label of OUD is all too readily given to anyone that claims to still have pain that severely restricts physical function after having been given pain medication. I know, because my doc suspected OUD with me, when in reality, another med was causing out of control pain levels in me that were even more off the charts than before I got put on that med. This was verified years later by a specialist that told me that med does that to some people. Don’t get me wrong, after removing the offending med, I still have pain levels that prevent me from physically functioning because my doc also cut down my pain meds when she suspected OUD to begin with. I know it’s kind of off topic, but I wanted to bring it up because I literally bawled like a baby when I read an article written by a well informed and educated doctor about this very thing. I do NOT have any signs of addiction or OUD according to my counselor, that is also trained in substance abuse. He even vouched for me because of it. However, I still consider going to the street to look for pain relief, when I finish the taper, to be a viable option. Because I don’t have that many options anyway and the so-called alternatives that I do have are just as bad, if not worse. I want to live, I just don’t want to live like this. I don’t want to sit at home and suffer until I have a major health event that either further disables me or outright kills me and I do not want to have to end my own pain through suicide. I am generally a law abiding citizen however, I can’t help but think that going to the street to look for pain relief is really no different than going to the doctor anymore. Mainly because drug dealers and some doctors have the same thing in common. They’re obviously both in it for the money. Because if I was a doctor and I had signed up for it to take care of people, I would be taking care of people. Not letting people suffer out of fear of losing my precious license. I used to think that doctors became what they are because they wanted to help and take care of people. After dozens of horrible experiences with the medical community, which began after starting MAT to treat chronic pain, I no longer think that way. Im not saying all doctors or healthcare workers are that way, but I’ve seen far more than I care to out of a good portion of them, personally. I am not going to go to the streets looking to get high if I do, I’m going to the streets to look for pain control and if that kills me, well, at least I won’t have to suffer anymore. Maybe I’ll die comfortably instead of in excruciating pain. Maybe not. But I see it as a far better option than suffering until I have a heart attack or stroke out or suffering the emotional (and physical) pain of waiting to die if I were to plan and execute a suicide. Hopefully I don’t end up in jail, because I know I’ll die there instead of at home, if I do go to the streets. Unfortunately, my disease laughs at their proposed alternative treatments, because it’s a cruel diease, that makes me suffer and beg for help.The idea of doing almost all of the same things I tried before MAT to control it is ludicrous. Those things have already failed me. All of these other so-called options (dirty little secret options, as I call them) have a catch to them, but we are forced to think about these things when they take away legally prescribed medications for legitimate and well documented painful conditions. They’re not just taking away medications, they’re taking whatever semblance of life that we had with them. They’re forcing our hands. It’s sickening. I’ve been a compliant patient for years. I’ve had to prove myself because I was young when I started having pain that I could no longer deal with and now that means absolutely nothing. All for naught, because this is going ahead, full steam. We suffer because whether or not the guidelines were meant to be taken as a mandate, they are. Personally, I think they knew they would be. They counted on it. Why else would they be charging and jailing doctors for supposed ‘over prescribing’? They fed the fear and watched it go down just the way they wanted it to. And we suffer the consequences, with no one wanting to hear our side. Disgusting. To think that I’ve been reduced to thinking about shopping the streets to take care of my pain, pain I didn’t ask for nor do I want, disgusts me. Where are all the cowboy doctors? The ones who knew the difference between right and wrong .The ones who had a moral and ethical compass that dictated their decisions, instead of playing pacifist and rolling over. Oh yeah, that’s right, they targeted them first so they could scare anyone else that might think of speaking up into submission. Law enforcement tactics, yet they still call the guidelines ‘voluntary’. Yeah, right.
The CDC “guideline” for opioid prescribing physicians will no doubt be the cause of my death. The cause in fact because the 24/7 pain from my health issue is not humanly tolerable without adequate medication that temporarily lowers the level of constant pain. No need to elaborate further. My death will only affect a very few immediate family members and by this fact, it is perfectly acceptable to the CDC opioid prescribing guideline authors, Dennis, Houry, and the rest of the committee members that have decided the fate for millions of pain management patients. I along with countless other patients were forced to reduce pain medication. I was forced to reduce my medication at the beginning of 2017 used for 23 years by 80 percent in 8 weeks. With my previous dosage of medication I was able to continue to own and operate my small business of 35 years, 23 years under adequate, monitored and documented opioid medication. I never dreamed that a US citizen could be tried, found guilty, and punished without due process but I have never had to deal with CDC “policy”. A “policy” that DEA is enforcing. I know for a fact that if a particular physician prescribes in access of 90 mme, the DEA springs into action and like pharmacist Steve has spoken of in his article, this is NOT how the CDC meant for the “guideline” to be implemented. I twill be MUCH more humane to allow al pain management patients that require more than 90 mme to be allowed to be euthanized……..legally.