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.

advertisement

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.

Newsletters

Sign up for our First Opinion newsletter

Please enter a valid email address.

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.

Leave a Comment

Please enter your name.
Please enter a comment.

  • I am a 60 year old man with Degenerative Disc Disease that was diagnosed almost 30 years ago. Since then I have had multiple disc bulges, herniations, desiccating discs and mobic changes to my vertebrae endplates. I have been in chronic pain management for the last 15 years and have every kind of non-surgical intervention available. None produced any lasting effect and most had no effect at all. For the last 12 years I have been on a stable opioid medication regimen that keeps my pain at a tolerable level about 85% of the time. I work as a psychotherapist so there are some days when prolonged sitting produces a more intense level of pain by the end of the day. Likewise, my condition is degenerative so it has and will continue to worsened. However, my need to maintain cognitive clarity has made me resist requesting any increase in my medication for the last decade. After moving across the country six years ago, my new PCP referred me to a local pain management clinic and everything continued as it had prior to moving. I have never requested an increase, failed a urine screen, “lost” a prescription or in any way violated my “pain contract”. Nevertheless, approximately two months ago the PA that I had seen every three months for the last six years informed me that she would no longer treat me, that she would give me one last 30 day supply and that I had to find a new pain management provider. I was speechless. I didn’t realize then that I had been caught up in a pharmaceutical witchhunt that had been increasingly victimizing chronic pain patients throughout the country for the last three years. I soon found out that no providers were willing to take on any new pain patients requiring opioid medication, in fact, many of them were also terminating existing patients. My PCP left the practice last April and despite the 15 years of medical documentation, my current doctor stated she is “not comfortable” prescribing me opioids. I explained that I was having severe pain episodes as well as early withdrawal symptoms because I would forgo medication on weekends and save it for workdays. She feigned sympathy but refused to help me. Once I had used up the final one month supply I was given, I began taking leftovers of old expired prescriptions, first mine and then those of sympathetic friends. At this point, I spend more and more time in bed because although the pain is constant, it’s worse if I’m standing or sitting. I’ve had to stop taking new patients and unless I can find a source for medication, I’ll have to close my practice. I frequently used CBT and mindfulness therapy in my practice and when I read articles that state these are useful in the treatment of moderate or severe chronic pain I have to laugh. These “studies” like so much of the ridiculous misinformation on alternative treatments is clearly being put out by people with no first-hand experience with that kind of pain. There is a reason that increasing numbers of chronic pain patients are committing suicide or turning to street drugs like heroin. On the days that I don’t take any medication, I find myself increasingly thinking of those as viable options. It’s impossible not to when I’m lying in bed consumed by pain that is so intense that it completely fills my perceptual field making it impossible to think about anything but how much it hurts and how to make it stop. What is happening to millions of chronic pain patients like myself is nothing short of institutionalized torture and is especially heinous in view of the fact that the increasing restrictions on prescription opioids no longer has any connection to the Opioid Overdose Epidemic. The fact is opioid related deaths have continued to rise every year even though the number of opioid prescriptions have decreased every year since 2011. Obviously the opioids responsible for the continually increasing numbers of overdose deaths are not prescription drugs but rather the illegal fentanyl and heroin pouring into the country to fill the void left by the 55% decrease in the country’s production of pain medications. But the DEA and other government agencies have an epic record of failure when it comes to stopping the influx of illegal drugs and the current illicit opioid trade will be no different. So in an America where public perception trumps truth, they are trying to keep the public focused on an old problem that has been resolved, in order to minimize awareness of the real problem, one they are helpless to control…even if by doing so they are harming many, many more Americans than they’re helping.

    • Jay I am so sorry that you are suffering, as more and more Americans have been in recent years, thanks to the efforts of our government.

      The drug warriors aren’t treating pain patients like criminals – we are treated worse than criminals. Notice how they’re still on a mission to reduce legitimate prescriptions, even though their own numbers don’t support any connection between prescriptions to pain patients and the supposed spike in deaths.

      Meanwhile, our tax dollars pay for free needles are given to people for the purpose of injecting illegally-purchased drugs. Injecting is far more dangerous than swallowing a pill – it can introduce infectious organisms, the whole dose is available in the bloodstream right away and street drugs are often cut with other substances to stretch supplies and increase profits. The substances used to cut the drugs are often dangerous by themselves. As far back as the mid 1960s, Dr Michael Baden (then an ME in NY State) tried to warn the public that it was the cutting agents that caused death, and many cause death by anaphylaxis or Stevens Johnson Syndrome – which cause extremely rapid closing of airways leading to death (as opposed to opiate OD, which is a 1-12 hour long process that starts with unconsciousness, and slides into a feedback loop of slower breathing leading to lower blood oxygen leading to fewer signals to the lungs to breathe).

      I haven’t seen any government official or media outlet even mention needle exchanges when discussing the supposed opiate death epidemic.

      The main problem as I see it is that without pain medications, pain patients are rendered unable to mass in the streets to demand redress of our grievances.

  • This is all just getting to be just so crazy ! As mentioned, when medications are available to help !! I’m not sure what’s going to happen this next week Tuesday. Since I’m still taking pain medication & yes!!! It’s been the only thing to help. I’m sure we’ve all tried so many other options, that made things worse & took a awhile to heal from. I had a chiropractor , who said he would NO longer treat me , because of how bad my back had gotten . He didn’t want to take any chances ! All these other treatments might work for some . Kentucky has been the worse place , to find the right help ! I have dropped down as much as I can on taking a pain pill. Been sick in bad so much from those muscle relaxers!! The anxiety had gotten so much worse & looking for a decent psychiatrist around here is almost impossible. I’m surprise the pain hasn’t gotten much worse than it has, probably because of the muscle relaxers. You can’t just keep taking all the Tylenol ibuprofen and muscle relaxers! I just can’t believe when medications are so readily available that we ourselves should also be able To write up a contract with our doctor for proper care & understanding !! So hard to take care of the things you need to without getting hurt . Thank you for the information & will be filling out the forms ! It’s just seeming like it all happening to late for so many !! I had put in a message a place that wants to hear from those that are being affected by all this treatments & doctors. !! I didn’t look for it to put it back on here. Sorry , it’s been crazy week , I’m sure for so many ! The weather doesn’t help. To be able to sleep would great ! Without having to take anything else. They only give me & others flexeril or such ! It can help but then you can’t get out or move to well !! As someone else mentioned, how many more will have to die before anything really gets better. It’s horrible when this pain hits & you find any relief. I don’t want to go, I’ve known several who have & it’s just a travesty! We no our bodies ! We’ve tried everything else , it’ should be just that simple!! Thanks, I hope everyone will be ok. If my legs etc. would stop burning or hurting. The only thing that helped was dilaudid. Good luck getting anything like that to help you. Even though I’m 57 & you’d think these doctors would realize that I’ve tried so many things . It’s also for those who are not that old & still need help fir pain. When docs say they’re to young & or it’s all in your head !! It’s crazy stupid. My best to you . I really am afraid that I might not get the help I need & what then ? It’s frightening. Sorry if I rambled on. I sent a email to that chronic pain place I put in another post. I hope all this can help.

    • It’s ironic that when the Congress first was considering restrictions on opiates that led to the Harrison Act of 1914, the doctors opposed it. Congress at the time promised that the law was all about illegal trade for illegitimate purposes and that it would never interfere with doctors and patients. I guess promises made by Congress have an expiration date.

  • It’s almost laughable…being a senior citizen. And thank God if you have a sense of humor, for without one, life would be so much harder. As seniors, we are looked at, all gray, fat, and crippled up, and that’s what our doctors see. What they dont see is…this could be them in 15 or 20 years. Some of us were beautiful, handsome, active, and loving life. Then age 54 or so, bang…arthritis hits, cancer, emphysema, all mind of afflictions. If they lived 10 or 15 years with chronic pain, they wouldn’t look so great, either. No feels like exercising when mere walking is painful. What they dont see is a human being, asking for some relief, so we may live our lives, do our own laundry, cook our own meals, and feel strong enough to visit our loved ones. What they dont see is our lives fading away in years of suffering, when we could be living again. Constant pain is depressing. I ,I’ve at a senior home, and many of us stay in bed, or sit most of the day because we cant deal with the pain. NSAIDs and exercise are rubbish. Neither helps. I was never lazy, had more than one job most of my working years. I practiced Tae Kwon Do in my 30s, and yoga and dancing in my 40s and early 50s. Now, I’m lucky to get to the bathroom in time. Pain is a killer. It kills your spirit and the desire to live. Doctors take an oath to “do no harm”, and yet they harm us, thousands, maybe millions of us, by turning us down when we ask for something to help with the pain. They run to their office or next patient and dont see us struggle to get back in our cars, let alone see us deal with housework and such. It is surely a crime to ignore pain and suffering!

  • Why is that happening to so many !! The medications that have been made to help & improve the quality of life especially the ones proven to help , like dilauded or such not being used ?! It’s been an absolutely horrible day! My legs I just can’t get any relief. Lol. I no you are also suffering! I’m so so disappointed in this USA !! & a friend in the UK says it seems they have it better. I just can’t take this much longer. Using a cream made for shingles. Helps some. It’s even in my hands. The body wasn’t ment to be in this much pain. I’m sorry to see the others on here suffering!! Best to you all

  • It’s a shame that we are assumed drug addicts just because we have pain and ask our doctors for meds. All I want is a few hours of pain free time so I can do my daily chores without agony. This ban has caused me to become a recluse, and I fight everyday not to cry to my son or friends for help. There is no quality of life as pain deters me from visiting my only grandson. I hate to let them see how crippled I’ve become. It’s been devastating. I have had severe osteo arthritis since 2004, thru no fault of my own, and NEVER have been prescribed pain killers. I’m 69 now, and the pain is getting much worse. Sometimes I lay in bed, wondering how much longer I can go on like this.

  • Thanks for the encouraging messages. Maybe just maybe this place that’s trying to get me in soon will be ok. I have some doubts , reading some reviews. Lol. Yet I’ve got to try & it’s just so nerve racking that so many places want to give those shots. As I mentioned I CAN NIT take those. That’s what made so many things worse. My sugar levels went crazy. It hurt like hell & DID NOT HELP ! Shame this happens to others. I’m sorry to read about all you thst are suffering & having to do something to find any relief. I hate to admit it even for myself , that I was able to get a few pain pills from someone. I hate doing that !! & we shouldn’t have to ! What else can we do when it’s that bad. The only thing that ever helped this horrible burning in my legs , feet & toes was dilautid , hope I spelled that ok. It wasn’t much in mg. But it helped so much. Yeah good luck getting something that really helps !! Like my headaches, that fioricet helped when nothing else would ! It even helped with some of this other pain & helped sleep some. Oh if it can help , why oh why would we let you feel better. Yes I read these messages & it makes me so sad to see the way humans are being treated !! Pain is pain ! Its just that simple !! & it can & will kill someone who just can’t take it anymore… I was able to get a bit sleep the other day. Was so great. The insomnia is another sad feeling to have to deal with. When your body wants it & yet it’s like your never tierd. The pain control helped. I can only say thank goodness I was able to get some help , or I truly don’t think I’d still be here. ! Now if the doctors would help with this leg pain !! Lol. My best to you all !! It is just getting to hard to keep doing this & the constant struggle. Even with the small amount of Ativan , the anxiety has gotten so much worse. Which the Physciatrist doesn’t seem to understand. The pharmacist does. It was helping , as he mentioned I probably just need an extra pill. I’ve been taking some magnesium which can help some with anxiety or sleep. Just can’t take to much … it helped 2day. Thanks again.. not taking the baclofen, caused my legs to swell. Back on the flexeril. It helps a bit with sleep but I don’t like it because you can’t move around much . It’s all I’ve got. Take care all !!

Sign up for our Daily Recap newsletter

A roundup of STAT’s top stories of the day in science and medicine

Privacy Policy