As a physician, I urge other doctors to cut back on prescribing opioids
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
It’s also painfully obvious that it’s Medicare, and Medicaid that is mainly focused on, setting-up a huge class division that doesn’t make sense to me because if most of us have adequate and quality medication, we could contribute more, have greater opportunities and the world will be better-off for it. With baby-boomers retiring, and more people than ever with an additional PTSD diagnoses, along with the restricting of Benzos; this is a set-up for horrific public unrest.
Thank God for the Protests all over the world as the whole oppressive theory is going to fail; it already has. Nothing good comes out of abuse and psychological terrorism, and a hi-tech Holocaust, [if severe and timely intervention isn’t yesterday] is about to combust. I met a young man at a local store, his truck was going in reverse by itself, then I saw him jump-in and put his foot on the brake. I said “good catch”, he asked if I had a cigarette, and said he was just abruptly cut-off from his opiate pain medication, and he has cancer. Then he said his brother is 65 with severe medical issues and was cut too. He seemed more concerned about his brother. WOW !!! This is serious psychopathic and cruel onslaught happening; a war with fierce hatred like i’ve never witnessed in my life. I told him to call someone. He said it’s not going to change anything. I said IT HAS TOO. THIS IS A CRIME, and every resulting suicide is a MURDER. I’m seriously considering massive brainwashing. The loss of empathy, compassion, and outright Sadism. I have to keep reminding myself that this is not the majority. The system has to go; it’s corrupt to the core. This is unnatural, and NOT OF GOD.
I could not agree w/u more,,,but how do we stop it????seriously..how do we the people stop this,,,,the government WANTS US DEAD,, soo,,,how do we seriously stop it,,when all the human right watch agency are too busy w/gay,muslim,,etc issues????I fear unless 1 of us literally win a huge lottery and use the monies to hire a private lawyer,,,were dead,,literally,,,,,Our deaths are murder,,we have all notified our senators,,the government knows what is happening to us,,soo this is ALLLL willfull,,,but how do we stop it?maryw
I know were being spied on,,,I don’t doubt ,”they” are ,”making” normal test results to take away medicine,,,With my recent surgery,,it made me realize that not all medical imagery see everything,,,its 2 d not 3 d,,and well if a surgeon see your organs ,”badly beaten up,,calcified,,and the ct done 72 hours before shows nothing ,,or the ultra sound show ,”a little enlargement,”’ when the real;ity is,,,they are destroyed,,,,,,”’they know this fact,”,,,yet alllow people to suffer in physical pain ,,,and tell them ,”everything is now normal,,” a bit scared,,but its ok,,,,bullshit,,For whatever brigatry reason,,they see our medicine as some demon,,,,,thier the wacko’s,,,,not us,,,and I always try to think,,its not about us,,,its about the next generation,,,our dead,,,that we most get thing BACK TO NORMAL,,, where as free adults,,we the right to choose the medicine that works for us,,and thee amount that works for our bodies,,,,not,,,,,Dr.Government,,,,,,mary
What I know from my experience, and what has not been considered because of the MISUSE and ABUSES-USING TECHNOLOGY is that many people, especially those who are “hypervigilent”sense when something is very wrong and many people in diverse positions from public defenders office, to non-profits for advocacy, -to unusual notices displayed on public boards, logos on vehicles, and other advertisements, are noticed and recorded in my brain as unusual and containing dark hidden messages. There are many of us who have cancer not diagnosed, but suspected, [my medical report states cancer can’t be ruled-out until major surgery], “Lyme” tests for the majority who can’t afford I GENX, are pathetically inaccurate such as the situation with my sister, who lost everything and became clinically diagnosed after 2 years of unnecessary operations and after it broke the blood brain barrier., Disabled and now part of the war on patients. 7 years later, and due to the intentional with-holding of positive blood-work for mos, may very well have cancer that may have been halted if addressed in a timely manner-such-as the careless disregard and cover-up of former research, diagnoses, and treatment for “lyme” still is now.
Before and after the “Reform”, and with my active participation in an unusually INTENSE but unique, “private” therapy, I was “shock & awed” to near suicide many times. I had my authentic and adequate medications then, [all controlled, due to multiple diagnoses]. Harvard traumatologists were [unknown to me at the time], advocating “exposure” treatment/ therapy. For someone like myself, who had been abused as a child in “public”, and who dropped-out of anything having to do with a public speaking course at college; the disturbingly “quiet” affect from too many people acting strangely was/is still surreal. My sister who, once healthy but now extremely damaged and increasingly in an emergency state with the “politically taboo diagnoses of “Chronic Lyme” disease, is being reduced, abused, neglected, and receiving the same misrepresented medication as myself, only that she can no-longer make the connections about their toxic nature, like I can.
I have been paralyzed with fear 24/7 [with professional help] for too many years. By the time I process one thing, 5 more bizarre events take place.
I now know beyond a shadow of doubt that I was/am being “watched, monitored, recorded,tracked, and set-up by the very “professional”, with who I entrusted my care.
It’s so bad now because the “energies” are palpable. Extreme temperature changes both external and internal, electronics come on by themselves, my computer wont send only my emails for help, my new 15th ADHD Brand-Name, 700.00/mo med is just as toxic as the rest; 7th version of oxycodone, [including brand name] is full of metals too, and I feel damage as never before.
No-one would believe me if I told them, except for very few who are sick themselves. My nervous system, liver, brain, and ability to function is deteriorating so fast, and I can’t receive any support because others are PTSDd, and people in the know-KNOW THAT we are being spied-on, so they stay away. Non Profits, [paid by gov] told not to help; N.Y.ACLU and other legal orgs are broke. The whole reason why we have the RIGHTS WE HAD, are exactly because of the atrocities that are happening now.
Hollywood Movie makers can create amazing “special effects” They can CUT & PASTE, VOICE REORGANIZATION, VOICE-OVERS……Evidence-Based, can not be considered TRUE when PSYOPS & EXPERIMENTAL ingredients are covertly put in meds, as-well as the transfer of smells, “touch”, subliminal sounds suggesting ??? This is the end game; I didn’t come this far to die in hell
We knew this alll along,,,,,it is literally,,,,torture and genocide committed by government employee’s,with there use of fear/regulation on our doctors,,and SOME/A LOT of doctors being cowards,,,,,,,they mary