A

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.

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 use to think the USofA was a great nation,land of the free. Now,I wish I could get as far away as possible from the USA and live almost any where else. Land of the free to me is just a joke that nobody laughs about anymore. Our health care is even more of a joke and what do we need doctor’s for anymore when everybody else tells them what they can and can’t do for there patients. I’d love to reverse rolls for a year and all of a sudden tell the CDC,president,government and everyone else that was on pain medication enjoying there life going to work and functioning as a whole leading a normal and productive life because their chronic pain was being managed by their doctor,the retirees were able to take care of themselves keep up their yards and still able to work on their cars and even enjoy their golden years etc,etc. HEY, not going to happen anymore guys,I’ve decided to punish you and take away your quality of life because of what the other’s are up to and it will make me look good in front of the people that really don’t matter. I have no idea what an impact it will have on you and I really don’t care,CDC says this is the way it is,handle it. We (the USofA) are going to hell in a hand bag. I wonder how many people’s of different countries are laughing at us right now? We are so divided right now. United we stand divided we fall. We seam to have forgotten that saying,we have forgotten what it’s like to care about one another.Compassion,I’m afraid to look that one up in the dictionary for fear that it’s not even in the dictionary anymore. All that I’ve said is only how I feel and not meant to hurt or start anything else with anyone else. Sincerely.

    • Michael, first l have to tell you that l am so sorry about the suffering inflicted on you by our government. I see your comment as a perfect demonstration of the insanity of the drug war – punishing law-abiding pain patients because of the bad behavior of *other* people, particularly criminals who have learned that blaming their crimes on drugs gets them lesser punishments (inmates in prisons for crimes unrelated to drugs with no documented history of drug use can get privileges like better housing for participating in drug “education” – basically learning to parrot the drug warriors ‘ narrative)

      And nobody in our government sees the insanity of trying to win the drug war on the backs of people with health problems that cause severe pain.

  • While I applaud this well-written, accurately referenced and substantially correct article by two recognized experts…it does not change my mind about a “pain-treatment strike” which should be implemented for the very reasons documented in this great article.

    Please recall that 45 miles “up the road” where one of these authors practices ( Pittsburgh ) and where my cousin is a respected “anchor” newscaster…I got “tarred and feathered” in the Courtroom of Judge Dominick Motto of The Court of Common Pleas of Lawrence County, Pa., because, after everything at my 2007 trial was “said and done”…I went to prison for over 8 years and lost my career; because I believed that five patients would continue to benefit from my prescribing of opioids — which was nothing more than the continuation of opioid prescribing by former doctors…none of whom were ever arrested or prosecuted… in these five patients, all of whom had prior histories of trauma more than sufficient to have supported the complaints of refractory pain.

    Until doctors learn that they just can’t “shut patients lof” without consequences; all of this correctness documented by these authors will not mean a thing to most people who are scheduled to see their pain doctor in follow-up…”TOMORROW.”

    William Mangino II, M.D. Anesthesiologist

  • I was in your position just 3 short months ago. Reading your post makes my heart hurt cause I also am a chronic pain suffer. For the last 10 yrs I was bed ridden most of the time. Bawling always, screaming out in the middle of the night from the pain that always kept me awake. The constant throbbing, burning & the fire in my legs, back, neck, arms & hands was constant day & night. I was on 100 mg Daladid & my pain raged above a 10 on most days. I tried all types of Narcotics & had too many to count Injections in my neck & back that caused severe Caterscts. I had countless surgeries in my neck & back that caused my pain to rage more. My life was over, I had given up the day my life was saved. I had heard of people having pain relief from the drug Bubenorphine but I associated it with being a drug addicted so I resisted trying it. The day I tried it my life was over, I just couldn’t go on another day in that pain fog. I thank god every day for my new medicine , my life has started again. I am 60% better I sleep like a baby, no more crying, I am active & no more pain fog. I hope you find the best solution for your self.

  • Opioid keep me alive for 12 years.Before the Smart Doctors founded out some of the reasons that was causing me to hurt.They found out that my heart had 4 blocks a widow maker the stress test I was in good shape before they found it by accident. Plus I have never and back damage.Still on opioid.But the meds for pain they make want whiskey and changes my mood makes me mean

  • I was on 60 mg of morphine 3 x’s a day. Plus Norcol 10 mg. 4 x’s a day. I had no pain at all and was able to walk my dog. Swim and walk to the the store. Clean my home, and play with my 10 grandchildren Then my doctor reduced my morphine. 30 mg. 2 x’s a day and my Norcol to 3 x’s a day. I went back in a month and he then reduced my morphine to 30 mg. 2 x’s a day. Withdraws both times. Now i went back today and he reduced my morphine to 15mg 2 x’s a day. He wants me back in a month. He says he is getting me off all pain meds.. I started crying in his office. I have severe fibromyalgia, severe schiosis, arthritis in my center back. I have a disc disease in my back where some are out of place and some are leaking. My lilliac artiries that feed oxygen to my legs are clogged with plaque. So now i will go through withdraws again. He says he has too or he could lose his liscense. Well i have been on pain meds for over 10 years. I never asked for them early or abused them. Now i just won’t walk my dog, sweep or vaccum my floors, or walk to the store on a good day. As those good days are gone. I am only 58. I have 4 children and 10 grandchildren. Now they won’t remember Grandma as i was. Only as someone who complained about her back and legs. Plus i can’t go for walks with them. What kind of life do i have left. Just lying in bed. I sometimes wish God would take me home. IT HURTS and i can’t sleep. IT HURTS and i can’t walk. What am i to do ?

  • First let us look at the so called pain management all they want to do is give epidural over and over again! Which is steroids What happens when so many steroids are put in your body it causes brain cancer. As well as they do not work. Those of us who suffer from chronic pain are not addicted before you judge us they need to take a hard look at theirselves. I can promise you if they spent even one day in our bodies their out look would be totally different!
    Respectfully
    Dorothy

  • The DEA bastards just killed me, they are dropping my pain medication that I have been using for 16 years there is a special place in he’ll for each and every one of them, With the medicine, I can still eat, without the medicine, I can’t eat as my pain is in my stomach. 2 Surgeries and a hoard of medical testing, plus a Federal Judge has said I was disabled, have proven my case and even though my pain is severe as cancer pain, I am no afforded the same level of care in this useless country.. And the suffering is horrible. Who the Hell gives these people authority over a licensed pain management doctor, I will be dead in a few days because of this poor Federal policy. Where the Hell is the President, the useless Congress and the ultra useless AG Sessions? Why is this being allowed in the US Banana Republic?

  • I am prohibited from getting opioids in the entire state of Texas my pain is tremendous and can be proven to be so by X-rays and surgeries that have failed I have a torn tendon part of my clavicle has been removed and am put together by screws and plates also my right knee needs total knee replacement the reason I got in trouble is because the Human resource office noticed the 100$ fee on My Medicare Insurance for Drs visits and took it upon it self to slap my hands aswell as the Prescribing Dr. now I am left with no medicine for my pain

  • Sarah, in your response to Billie Mansfield….It is an unfair situation and physicians are being threatened with loss of licenses if they prescribe too many narcotics to anyone. They are all scared and unfortunately, the public are caught in the middle between the medical industrial complex and our doctors. Many doctors have already have had their DEA licenses revoked and are legally unable to prescribe any narcotics any further due to probes that have found out a long period of prescribing these drugs to people and not offering any other types of treatment. As a nurse of over 30yrs, I believe it to be a breach of their Hippocratic Oath “to do no harm”. Perhaps lawsuits would be beneficial in bringing concern to the government agencies that are complicit with insurance companies and drug companies that have perpetrated this ridiculous and unethical handling of chronic pain patients. If you have time, watch the PBS video I linked on an earlier comment today. It will outline the basics of this problem. Unfortunately, it now involves pharmacists. They are acting like physicians and not filling scripts if they judge someone to be abusing narcotics. They are also being sued if they do fill a narcotic script and a patient dies from an overdose. This situation is a lose-lose for everyone involved. I don’t know what it will take for a resolution now that the government has made all providers spy and report on each other based on assumptions.

    • First you are completely right first do no harm!!! Second we are not children. If these people did their research they would find out all of us are up in age. All I have heard is shot”s in the back. If you research this it is a massive amount of steroids which cause”s brain cancer!!! And does not help the anyone. If you research people who live in chronic pain you do not become addicted. Pain medication takes the edge off but that is all!!!
      I wish all the best and please know
      you are not alone I suffer just like all of you. I say walk a mile in our shoes.

  • I’m a patient who has been on opioids for 26 years with Arachnoiditis.
    I had five back surgeries and a fusion also a broken t6. Now I’m told on July 1, 2018, no more meds as I was being treated by my MD for the last 9 years
    This gives me two months to find another doctor. The law needs to be rewritten to have those who are in active treatment be allowed to keep their doctor.

    • Okay now that just pisses me off more sorry for the language but come on this comment is to Billie Mansfield don’t know if you will ever see this, BUT that is just stupid and horrible I would sue because by law your doctor has to help you because I am sure by now your most likely addicted to them, and if your MD has been helping you for 9 years he can’t legally just say okay I give you only two months It has to be illegal Please Billie look into it to see if its legal if not sue there butt off!

Sign up for our Morning Rounds newsletter

Your daily dose of what’s new in health and medicine.

Privacy Policy