Amid 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 was in a terrible accident when i was 18 and im now 35. I shattered my hip and various other injuries and was in a coma for 3 months. Now i use my meds for pain to get around and work for the state of florida. My question is how and who do we advocate our voice and our opinion too for stopping this chaos and absolute nightmare ? It HAS TO STOP SOMEWHERE ,AND WHEN WE TRY TO SAY ANYTHING WE ALL LOOK LIKE ADDICTS WHEN ALL WE WANT IS TO LIVE OUR LIVES PAIN FREE AND WITHOUT JUDGEMENT OF THE ONES WHO ARE CREATING THIS HAVOC

    • Christopher, I am so sorry you are among the chronic severe pain population. We are definitely being ignored while the drug warriors just keep demanding more of the failed drug war. We need to get more attention to this issue – as much as we can and as soon as possible.

      Today I plan to write a letter to the president. I’m using real paper, sending it through US mail because this is taken more seriously by politicians than emails or petitions. My letter will ask this question, “Mr. President, have you discussed opiate policy with a single law abiding citizen who suffers chronic severe pain? If not, why not?”

      I hope others reading this will consider sending similar letters to the president – trying if possible to get them into the mail tomorrow, so they all have the same date on the post mark, and arrive as a group.

    • Watch for announcement at http://givepainavoice.org, of a new legal aid charity to be called GivePainAVoiceInCourt. Our group is seeking patients like Christopher, who use medication to ameliorate a painful disability and derive the same benefit from their pain medicine, that a one-legged person gains from a prosthetic leg or a hearing-impaired person gains from a hearing aid. We would not attack a heart patient as an “oxygen addict”, merely because she depends on oxygen to stay alive. Neither should pain patients be attacked, for using Opiate supplements to help them function. Disability discrimination is unlawful in nearly all cases, and we intend to defend those legal rights for patients, in court. We thought long and hard about Christopher’s question and the answer we reached, is that the best place to speak out, is in the courts. Other people pretend to speak for us in court; since they are not pain patients, they get the facts wrong. Our voices must be heard in court, or jurors and judges will continue to be misled.

    • Bob, l was just seeing my pain prescriber yesterday & l mentioned to him that criminals who are convicted of drug infractions can appeal their sentences but law abiding citizens with pain can’t appeal being deprived of sufficient medications.

  • 500,000 people die every year from smoking cigarettes, yet there is no one stoping the production of cigarettes or any cuts to these addicts supply. This is nothing more than what a few regulators deem necessary. Unfournitly we as pain patients, dont have large sums of money to afford lobyist as to protect our medical rights. Its all the DEA’s war on drug failure so now they are gunning for the weak and defenseless who can barely get by. Cigarettes are a acceptable addiction but no not opiates. Wonder why 10 times more deaths in a year. Its all BS.

    • It’s even worse than you describe. Not only do cigarettes kill half a million people per year, but they can kill someone who quit DECADES ago. Tobacco causes damage to every organ system of the body – from the characteristic mouth wrinkles (and skin in general), to the stomach, kidneys, liver, intestines, reproductive organs, and lungs and heart….

      Meanwhile, opiates do not cause damage to any organs. Also, opiate overdose is nothing like what we have been propagandized to believe, with the person dying so quickly there’s no time to pull the needle out of the vein. That kind of death is typical of anaphylaxis or Stevens Johnson syndrome – both of which cause rapid closing of the airways, both of which can be triggered by any one of the many substances black market dealers use to cut heroin. Meanwhile, actual opiate overdose takes 1-12 hours, during which a high dose causes both unconsciousness (not instantly), and lower blood oxygen leading to less frequent signals from the brain to the lungs to breathe, leading to even lower oxygen levels – and if this feedback loop is not interrupted, the person can die. If the process IS interrupted, the person comes back to consciousness with no permanent damage – including to the brain.

      I’m going to write a letter to the president – on paper, sent by mail – posing one question, “Mr President, have you discussed opiates with a single law-abiding citizen with chronic severe pain?” I hope you will consider writing such a letter as well. We may not have money, or lobbyists, but we do have the right to request redress of grievances, so we could start with that.

      I also think we need to brainstorm ways to call attention to the cruelty of the situation of pain patients, and make America Ashamed that we have allowed this to go on as long as it has.

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