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mid a rising toll of opioid overdoses, recommendations discouraging their use to treat pain seem to make sense. Yet the devil is in the details: how recommendations play out in real life can harm the very patients they purport to protect. A new proposal from the Centers for Medicare and Medicaid Services to enforce hard limits on opioid dosing is a dangerous case in point.

There’s no doubt that we needed to curtail the opioid supply. The decade of 2001-2011 saw a pattern of increasing prescriptions for these drugs, often without attention to risks of overdose or addiction. Some patients developed addictions to them; estimates from the Centers for Disease Control and Prevention range from 0.7 percent to 6 percent. Worse, opioid pills became ubiquitous in communities across the country, spread through sale, theft, and sharing with others, notably with young adults.

The prescribing tide has turned: Private and governmental data show that the number of prescriptions for opioids has been falling since 2012. Reassuringly, federal surveys show that misuse of pain relievers bottomed out in 2014-15.

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Nevertheless, the CDC produced a guideline in 2016 that recommended shorter durations for opioid prescriptions and the use of non-drug treatments for pain. It also suggested keeping opioid doses lower than the equivalent of 90 milligrams of morphine. As the guideline acknowledged, its recommendations reflected weak scientific evidence. Problematically, it was silent on how to care for patients already receiving doses higher than the 90 milligram threshold.

To its credit, the guideline endorsed treating patients as individuals, not numbers. A CDC official wrote to one patient that the guideline “is not a rule, regulation, or law. … It is not intended to take away physician discretion or decision-making.”

Unfortunately, these mitigating features were undermined by intemperate publicity that vilified opioids for pain. Opioids for pain “are just as addictive is heroin,” proclaimed CDC Director Dr. Tom Frieden. Such statements buttress a fantasy that the tragedy of opioid overdoses and deaths will be solved in doctors’ offices, primarily by upending the care of 5 to 8 million Americans who receive opioids for pain, even when most individuals with opioid addiction did not start as pain patients.

The progression of the guidelines from “voluntary” to “enforceable” has culminated in a draft policy from CMS. It would block all prescriptions above the CDC threshold of 90 milligrams unless complex bureaucratic barriers are surmounted. Many pharmacy plans are already enforcing this approach. Under that plan, many patients suffering with chronic pain would lose access to the medicines they are currently taking, all in the name of reversing a tide of death increasingly defined by non-prescribed opioids such as heroin and fentanyl.

The logic of doing this is untested. There have been no prospective clinical studies to show that discontinuing opioids for currently stable pain patients helps those patients or anyone else. While doing so could help some, it will destabilize others and likely promote the use of heroin or other drugs. In effect, pain patients currently taking opioids long-term have become involuntary participants in an experiment, with their lives at stake.

Turning the voluntary guidelines into strict policy is unfortunate for three reasons.

First, it reflects a myopic misunderstanding of addiction’s causes, one at odds with a landmark report issued by the US surgeon general in November 2016. While the supply of drugs matters, whether people develop addiction to opioids reflects diverse factors including age, biology, and whether their lives include opportunities for rewarding activities like work and family or lacks those opportunities. Restricting prescriptions through aggressive regulation invites the outcomes seen in Prohibition, 90 years ago. To be fair to Prohibition, cirrhosis deaths did decline. But echoing that era’s gangsters and moonshine, we now face a galloping criminal trade in drugs of greater potency and lethality. Overdoses have skyrocketed, mostly from heroin and illicit fentanyl. In a Massachusetts review of overdoses, just 8 percent of those who had overdosed had received opioid prescriptions in the prior month.

Second, we have alternatives to bureaucratic controls. These include promoting and paying for treatments that de-emphasize pills. Important work by the Department of Veterans Affairs shows how to identify patients with elevated risk for harm from opioids and how to mitigate the risks.

Third and most troubling is the increasingly inhumane treatment of patients with chronic pain. Fearing investigation or sanction, physicians caring for patients on long-term opioids face a dire choice: to involuntarily terminate prescriptions for patients who are otherwise stable, or to carry on as embattled, unprotected professionals, subject to bureaucratic muscle and public shaming from every direction.

In this context, we cannot be surprised by a flurry of reports, in the press, social media, and the medical literature describing pain patients entering acute withdrawal, losing function, committing suicide, or dying in jail. The CMS policy, if adopted, will accelerate this trend.

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Many of our colleagues in addiction medicine tell us they are alarmed by the widespread mistreatment of pain patients. We receive anecdotes every week from physicians and pharmacists, most of them expert in addictions, describing pain patients who have involuntarily lost access to their pain medications and as a result have been reduced from working to bedridden adults, or who have become suicidal.

This loss of access occurs several ways. A pharmacy benefit program may refuse to cover the prescription because it has already enacted the changes that CMS is proposing to make mandatory. A physician may feel threatened by employers or regulators, and believes his or her professional survival depends on reducing opioid doses — involuntarily and without the patient’s consent — to thresholds that the CDC itself described as voluntary and not mandatory. Or state regulators have imposed such burdensome requirements that no physician in a given region can sustain prescriptions for their patients. Such patients are then “orphaned,” compelled to seek treatment from other physicians across the country.

Given the expertise in addiction among these physicians, it should be particularly worrisome that they believe the present pill-control campaign has gone too far. And yet, the ethics are clear: It should never be acceptable for us to countenance the death of one patient in the avowed service of protecting others, even more so when the projected benefit is unproven.

Surgeon General Dr. Vivek Murthy made an underappreciated declaration in a recent interview with the New England Journal of Medicine. “We cannot allow the pendulum to swing to the other extreme here, where we deny people who need opioid medications those actual medications. … We are trying to find an appropriate middle ground,” he said.

As addiction professionals, we agree wholeheartedly.

Stefan G. Kertesz, MD, and Adam J. Gordon, MD, are physicians in both internal medicine and addiction medicine. Dr. Kertesz is an associate professor of preventive medicine at the University of Alabama at Birmingham School of Medicine; Dr. Gordon is a professor of medicine at the University of Pittsburgh School of Medicine and editor of the journal Substance Abuse. The views expressed here are their own and do not reflect positions held by their employers.

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  • Firstly I want to thank you for your articles and for standing up for people who suffer from chronic often times incurable pain.
    I have severe Crohn’s disease, multiple sclerosis, chronic regional pain syndrome formerly RSD and damage in my spine from osteomyelitis and discitis at L1 L2. I now face a major back surgery due to the damage from the infection.
    To say I suffer from daily severe pain is an understatement. I recently relocated to Texas from Washington state to be closer to family. My MS diagnosis is very recent and caused by the Humira I was taking for my severe Crohn’s disease. My sister and brother in law are both retired physicians and are doing their best to help me get through the war on pain patients “my term” on this supposed epidemic!
    The way I see it, is drug addicts will find their drugs no matter what. Since People with chronic pain have been cut off their medications or drastically reduced the folks abusing opiates have moved on. They now use cheaper heroin and fentanyl. And we the people who truly suffer are collateral damage. Know one in the media mentions us! The media propaganda has mislead the public!
    Which now has caused a stigma for us if we are fortunate enough to get the medication we need to function.
    And this is the truth of what is happening! Dug addicts continue to get high and overdose. These statistics get confused and/or purposely mislead giving the government reasons/excuses to cut pain patients off their much needed life functioning medications.
    Would they cut people with diabetes off insulin? Or a person with cancer off their chemotherapeutic medications? There is NO difference.
    If I did not have my opioid medications I would be bedridden and unable to have any quality of life.
    I found out how strict Washington State is compared to Texas. My physician in Washington did his best but I definitely did not ask for any help if my pain wasn’t controlled. I went to my monthly appointment with embarrassment as I gave my monthly urine so that I could get a prescription that was being widdled down with each appointment. I had no life! My pain was out of control and my family in Texas came up and moved me.
    I was terrified when I went to my first appointment with my pain specialist here in Texas. I didn’t know what expect! To my surprise I wax treated with respect and dignity! My new doctor read through my chart and told me that he did not want me to suffer. And after a lengthy discussion he agreed that I was not on enough medication to control my severe pain. I am now able to function again! With the help of my family I am remodeling my house in Texas to make it handicap accessible. I’m not able to do any physical labor but I am involved and participating in life.
    I honestly don’t know what’s going to happen to me if the CDC guildlines become “law”.
    I know it will significantly reduce any quality of life I regained and I’m afraid it could kill me.
    I hope my story gives others hope. Hope that not all doctors are scared to treat their patients. I hope and pray for others and for myself. Please God spare the people that are truly suffering. We do not deserve to be treated with less compassion than an injured animal.
    Patty Davidson

  • I am a chronic pain sufferer. I have ALWAYS taken my pain medication like I am supposed to. NOT ONCE have I EVER failed a drug test, Doctor shopped or broken the law. This new law in reducing a person medication for pain is OUTRAGOUS!!!! The theory of these new laws of reducing or completely cutting off pain medication from chronic pain sufferers to prevent overdosing resulting in death is unproven!!!! There are some people in which I agree that abuses pain medicine. Those people should be punished NOT those who have ALWAYS obeyed the law and have NEVER broke the rules or the law!!!!!! The government is affecting people healthcare and it is WRONG!!!! I guess the government would rather chronic pain sufferers such as myself suffer and be on disability, be bed ridden and have NO quality of life WHATSOEVER than to trust us as adults that can manage taking our medication properly!!! Their punishing the wrong people!!!! Trust that our physicians and us as adults that deserve a good quality of life to prescribe and take our medicine correctly. It’s not for the government officials to decide our way of life. If they was chronic pain sufferers like we are I GURANTEE you they would be on pain medicine as quick as they could say ouch!!! Don’t punish us for what you think is best for our health issues. That’s for qualified physicians to make!!!! NOT THE GOVERNMENT!!! If you want to make rules and guidelines for physicians and patients to follow and then IF they fall short or fail to adhere to the rules/laws then and ONLY then enforce the action of removing them from being able to have pain medications. But NOT law abiding citizens that just wants to live a good quality of life. All pain sufferers raise your voices, let your state representative know how you feel and make them realize that if was not for your voting right they would not have a job!!! Remind them that their job is to listen to the American people and adhere to their rights and NOT make it their personal mission to make law abiding citizens suffer for other people’s stupidity!!! Make some noise!! Let’s band together and make them see the light and make a new law where there are exceptions to patients who suffer chronic pain daily who have never had any issues abusing their medication!!! PUNISH THE RIGHT PEOPLE!!!!

  • I have had 5 surgeries due to my endometriosis, including a complete hysterectomy and a colon resection. I am still in excruciating chronic pain. Every day, all day. The only thing that kept me from committing suicide was the pain medication I was prescribed. This is something I have been dealing with since I was 14 years old (pain and endometriosis). After there was nothing left to do surgically, I was sent to a pain management doctor. I have tried everything from biofeedback to trigger point injections, to blocks, to colonics, to acupuncture and a million more things along the way. I felt like a guinea pig. The only thing that really gave me any relief or quality of life, was the pain medication. I had an amazing doctor who fought the good fight for pain patients. He was strict, made us keep daily records of our pain levels every few hours, but he was also compassionate and not afraid to prescribe what helped his patients. Of course we had to do regular urine tests, (for our own safety). Since I have been dealing with this illness since I was 14 years old, I have been on some sort of opiate off and on or continually for 24 years. That increases a person’s tolerance. But my doctor knew my history and made sure that I was not in pain 24/7. Unfortunately he got cancer and died very unexpectedly. This left me without a doctor overnight. No referral, no records (his office manager just closed the office with no warning), nothing. So I got together my own hospital records, surgery records, etc and went looking for another compassionate doctor. Unfortunately no doctor would take me without records, the referral of another doctor and on the high dose I was on. The new regulations had come into play. I was sh** out of luck. I was forced to go to the ER almost every 3 days and still no doctor outside of the ER would see me. So finally in my research I read about methadone clinics. I decided that I had no choice, either kill myself because I had no quality of life. I couldn’t work, couldn’t be around my friends or family, couldn’t even leave my bed most days. I went to the methadone clinic and pretended to be an addict, which I assure you I am not. They slowly raised my dose until I finally reached a level that made life bearable, not much quality of life, but at least bearable. I had to go into a clinic everyday to get my “dose” and be treated like I had done something wrong just to have even a third of the quality of life that the average person has. When they talk about lowering the dosing of opioids people like me are the ones who suffer. You can’t just make a blanket policy saying not to prescribe over the equivalent of 90 mg of morphine and expect that one size fits all. I was one of the patients receiving over the equivalent of 90 mg of morphine and when the last compassionate doctor I knew died, I was left out in the cold. I definitely wasn’t going to turn to illegal drugs or getting legal drugs illegally, but I had to do something I never thought I would do. I lined up every day with the heroine addicts or formerly addicted, although most are still using heroine on a regular basis. I have nothing against addiction and I truly believe it is a disease, but not one that I have. This is the so-called “War on Opiates”. This is what it’s doing to honest, chronically ill and in-pain patients. I have had to schedule my whole life around going to the clinic. Now I only go once every 2 weeks because I have NEVER failed a drug test, but I still have to GO TO A METHADONE CLINIC… and I don’t know how to get back to a pain management doctor. I have been robbed at the clinic, been threatened and treated with no respect what so ever by staff. I just wish that these bureaucrats would stop and think about if it were them or someone they cared about in this situation. I guess I am rambling now, but I ultimately just want to thank you for a very good article and for helping people to see this from other perspectives. Something has got to change.

  • For ANYONE who has had their medications reduced or cut off, get aggressive and make some noise. Contact your local media (especially television) and work to get your story out there. We need to get more of OUR story out there, especially to help counteract the ridiculous opioid hysteria propaganda. Contact anyone you can think of — reporting this obvious malpractice to your state board of medicine, insurance company (if you have one), keep the government busy answering your phone calls so that the lines get tied up. So far I’ve managed to get the attention of a local newspaper reporter, and more recently with a local TV reporter: http://www.abc15.com/news/state/chronic-pain-victims-share-other-side-of-prescription-drug-abuse-epidemic?autoplay=true

  • As a person with 12 diagnosed Autoimmune diseases I suffer from chronic pain along with other major health issues. I am NOT supposed to be under any stress because I do NOT produce cortisol, the stress hormone. I was recently cut off, cold turkey from both my opioid pain killers and my benzos taken only for stress or panic attacks. Thank you so much DEA for putting my life at risk. This is the most ridiculous thing that has EVER happened to me. I don’t take these pills for fun or a high. I take them for my chronic illnesses along with the other 20 scripts I am on. Thank you DEA for making it so that I am looking into Heroin to help me through my pain and now the withdrawal from the meds she has taken off of me. She told me I am on ‘too many meds’ and took my pain meds, benzos, anti-anxiety meds and threatened to take my insulin and steroids (both of which keep me ALIVE!). This is disgusting! It’s upsetting enough for me and it breaks my heart for those who are far worse off than I am. They are hurting more people now than they are helping. SICKENING!!!!!!

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