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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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  • I just received a letter from CVS Caremark. My insurance company through AT&T have cut my opiates in half with no prior notice. I will go through withdrawal and become bedridden. I have medication allergies and have few options. I will not be able to live without them.

  • I was on pain meds for chronic pain. Got taken off my doctor passed away. My son died 3 years ago of an accidental heroin overdose which had nothing to do with pain meds. It’s like these lawmakers don’t understand addiction

  • As a nurse of 36 years I whole-heartedly agree. Has become difficult to relieve pain for patients, even those in Nursing Homes! Stop this insanity. Dependence and addiction are not the same. True addicts will just find another substance, heroin and fentanyl usage is already increasing.

  • To Richard A “Red” Lawhern, Ph.D.,
    I hope I did not give the impression that I doubt the credentials of Dr. Kertesz. I thanked the authors of this article in a previous post because it seems like support for chronic pain patients is in the minority compared to the many negative news reports and many commercials for addiction services that are likely legitimate, but costly. I only spot-checked one addiction service commercial to see if they accept Medicaid or Medicare because I really believe addiction issues could be better helped if treatment services are offered to low-income people. They do not, and I suspect that’s the norm for those that are heavily advertising.

    I appreciate all those who actually have an understanding that for some of us, opiated pain medication has worked well, worked best, and that we should not all be classified as automatic candidates for addiction just because many of us will need this form of pain management long-term. Neither should all of us share the blame for the “Heroin Epidemic”.

    I feel that the information in articles like this one, is being overshadowed by negative news reports. The mainstream media gained enough outrage by calling it the “Heroin Epidemic”, but it seems like that term has gone down the “memory hole”, in favor of spinning “The Opiate Crisis” like a fidget toy. It’s misleading and helps justify more heavy-handed DEA regulations by putting pain management patients under the same umbrella as drug dealers and those who truly need help for addiction issues.

    Thank you Dr. Lawhern, Dr. Kertesz, and Dr. Gordon for advocating for us.

    • No worries, Paulette. I wrote primarily to reinforce Stefan’s credibility among other readers of this comment thread. I would encourage any of them to respond as they did — either here in the thread or by email.

      It is credible to argue that a major cause in the so-called “opioid crisis” is our very own FDA. When they mandated reformulation of Oxycontin in abuse-resistant form (in 2010), the number of prescriptions for this powerful pain reliever dropped by 2/3rds and deaths due to heroin tripled in the next five years. This is not an accidental relationship. Addicts who had been shamming their doctors for safe and regulated opioid pills found that the new form of Oxycontin no longer gave them a high. They went into the street and found that heroin was a lot cheaper and more available.

      I would also amplify on remarks by Margaret Aranda, whom I am pleased to claim as a colleague in this battle. It is my own view that the coerced tapering of patients who have long been stable on *any* dose of opioid analgesics, is a fundamental malpractice and abandonment of patients. Arguably, the denial of pain relief can be seen as a fundamental abuse of human rights.

      A reminder to all: I can be reached at lawhern@hotmail.com. I am actively recruiting pain patients and family members to schedule face to face interviews with the staffs of their Representatives and Senators, to convey this message: Congress can end a lot of the agony now unfolding among chronic pain communities. All they have to do is send the Director of the CDC a letter demanding that the 2016 opioid prescription guidelines be withdrawn for re-study and revision. It doesn’t even take a law!

      Go in Peace and Power
      Red

  • Just a note to thank you for this timely article that shows today’s frustrations of many patients and physicians.

    Encouraging patients to keep explaining their tapering here, as it provides validation and instruction back to this scenario.

    Thank you for showing that there are many doctors that hold the physician:patient bond wrapped in the Hippocratic oath.

  • I don’t know if this was a reply to me or someone else. I didn’t get an email alert for it, just found it scrolling through the older comments. I will also try to email because I didn’t see a reply button.

    Stefan G Kertesz
    JULY 26, 2017 AT 5:05 PM
    As co-author of the piece above, it sounds like you received a reduced prescription. I am interested in understanding how these changes to care are carried out.

    Are you comfortable stating
    (a) what was the prescription per month prior to its reduction;
    Oxycod/APAP 10/325MG TAB, 1 tablet every 4 hours as needed. 180tabs.
    My former primary resident explained they are only allowed to write for 30 days because “the DEA is breathing down our necks” <<that's a quote.
    (b) what was it afterward;
    Half 90 tabs
    (c) was there a conversation where this plan was explained to you before it happened;
    No. I had just seen my new primary resident doctor about a week before picking up my paper prescription. He said he was sorry, but he can't do much for me except continue to treat the symptoms, and offered to go ahead and print and sign my prescription while I was there (DEA regs). I said " no" because I had found out at my last prior visit to the pharmacy that the had a new rule saying the paper prescriptions expire in a week and my old prescription was still good. I signed my new "Pain Contract" (another DEA reg) which was only one page that time. The nurse had her hand over the writing, so I don't know what the new contract said. They are usually more than one page and that was the first time I did not receive a copy.
    (d) was there a plan proposed for how your care would change as the result of this change;
    Nope, that's why I asked the same nurse why it was half. I felt certain my new resident doctor would have said something if he had been aware of any more new changes since I had just had my appointment about a week prior.
    (e) what you are doing to cope now
    During the time I had 90 day rationing, it was unacceptable without my 180 tabs. When the doctor called back, he said he wrote for 90 because that's what the last 2 refills were for, and some patients are on 2 weeks. So now I am confused if I am staying on the rations or not, but I'm worried. I force myself out of bed because I have cats to feed. My grandsons are next door now, still in process of moving. I try to distract myself by interacting with the kids and cats as much as possible. I still pray.
    (f) what state are you located in?
    Ohio
    (g) did your doctor or his/her staff state a reason for these changes?
    I asked the nurse why my prescription was halved because my new doctor hadn't said anything. She left and came back and said it's something new they're doing with patients that have been on pain medication for a long time. I said please have the doctor call me because I felt there must be a reason for the drastic change, he didn't inform me in advance, and I felt that was crazy to suddenly cut a pain prescription in half. If a doctor needs to reduce the dosage, then how about a slow, careful taper down? Honestly, that would be a disaster if I have to be on half rations. My full 180 tabs were not a miracle in pain relief, but it worked for me enough to cope, and have a semblance of quality of life, and I did not want more. Right now, I don't know what my doctor is planning to do about the dosage. He went ahead and prescribed another 180 tabs, but now I'm confused if I'm staying on that or not since I found out about the latest CDC/DEA craziness. Does that mean my next prescription is still on the computer for 90 or 180 tabs. My doctor did not explain, and I didn't think to ask specifically after he assured me that he never told the nurse that. I thought that meant this was just a mistake.
    If you don’t wish to state publicly just email to me and Dr. Gordon. Our emails are on this article.

    • Paulette, Dr Kertescz is well known to me and others who write on opioid policy. He is a very well balanced and qualified advocate for people who are being harmed by the errors, omissions, and outright medical frauds contained in the CDC opioid guidelines.

      FYI: a 50% unilateral cut in opioid medications for a long time patient is widely recognized to be medical malpractice. Tapering guidelines published by CDC itself indicate maximum tapering rates on the order of 10% per week over periods of months. In my personal view, the forced tapering of a patient who is otherwise stable and well managed is medically unjustified patient abandonment and abuse. Such patients have little or no risk for addiction, even when they are physically dependent on opioids for pain relief.

  • Hi ,
    Doug, I really think it’s maybe ironic that drs call withdrawal like a bad flu but yet, NONE have ever been through it. Paulette, I’ll email you soon. I’m in withdrawal since after yesterday’s appointment. Took my patched away and just on immediate release every 6 hours hours even though it only lasts 3. It’s been rough. Thank you Cincinnati VA. At least my dr there, referred me out to a real board certified pain mgt dr cause my case is too difficult. I guess he felt he needed to get me below the 100mg morphine equivalent first.

    • It’s totally okay Luanne, take your time and take it easy as possible. My heart goes out to you and to all of us. I’m sending you my best wishes. I looked at the Cincinnati VA hospital website and didn’t find much, like this wasn’t a major decision. I browsed around some other sites though, and was shocked to find that the VA had jumped on board with this. In the U.S., I would have thought the VA would be the first to go to bat for their patients, and stand up to those government brats. It’s a sad day. I hope you will be feeling better soon though. Email whenever you can, and stay strong.

  • I’ve been on very strong pain medacation since I was 13 years old I’m 62 now. My doctor of 27 years retired and his partner took over my case. The first time I saw him he cut me back 1/2 my medication and has cut me back 30 every 3 months. I was taking 12 30 MG a day. I am now down to 2 a day I have 4 headaches a day. I have chronic cluster headaches.
    What I wanna say is this these doctors though they were doing the right thing giving there patients large amounts of pills. Turning them in to addicts. And then making theme feel bad when they come to them.sick because of them taking them. Now because we have fools out there people who have no disability selling them.people dying from them , people like myself need these everyday. Even when taking 12 a day it still didn’t kill the pain. Now my pain is so bad I feel pain in my body I never felt before. And now that Im 62 they think now there doing the right thing taking them away from those who’s been on them for life and they CA you addicts. Da ass hole because you though your do I ng the right thing. And how after 45 years can’t I be a addict.they say it’s OK youll be fine its just like bad flu. Ha ha how about this you take them for a month and then let me.take.them.away from you and then till me.it’s like bad flu. The doctors have ruined many god people and matt r fact killed many because they can’t handle withdrawal. And NOTHING happens to these doctors. They walk away Scott free. Is that right? I want to.start a class action suit against the federal government and doctors and if you are people lie me who need them and have been on them for ever and never had a problem with your doctor’s for miss use please join me and 300 others who have joined me. You can reach me at doug5322@mail.Com it’s wrong what they are done to good people who didn’t ask to be done this way we trusted our “doctors”!!! With out lives only to be turned on. And it’s mostly the feds. Doctors don’t wanna loose there medical license for us. So we suffer. We have rights people and we as a.people need to speak up and be herd. Help me get our rights back to the people. Trump is goin to really turn us upside down so join us and let’s make history and show then we won’t allow them to use us as guinea pigs. Like they did in the war. In prisons.

  • Hi Cheryl,
    Please email me. It would be really nice to know someone close is in the same situation as me. I live NW of Cincinnati. Thanks!

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