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.


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 guess you would call me a pain patient. I have chronic back pain that has been documented by an M.R.I. I visited a doctor who cares for my father yesterday because I suffer from depression and he somewhat specializes in this area though he is family practice. I was forced to sign a form saying I could be subject to blood tests, I was not requesting pain meds. I have worked in nursing and have seen the rash of her ion that is sweeping this country. I truly believe the overdoses are due to illegal drugs that are entering the U.S. I receive prescription medication from my M.D. I would NEVER dream of selling my medication to anyone, I need it for my pain, so I can move. It makes me so angry to see how the government is turning this around. What about E.T.O.H.? Which is freely available to anyone? My spouse is an alcoholic. No where is there anything to stop him from what he is doing, killing himself. And why? I believe its called profit. If there is an epidemic in this country, why don’t they look at the sources? I am so angered by all of this. I worked on the coast in Washington State in a small town where a famous dead musician came from, Kurt Cobain. I was shocked by the number of young women who are addicted to illicit IV drugs, and become pregnant because they prostitute themselves, to support their habit, and give birth to addicted babies. The state is overwhelmed with these poor infants who suffer beyond belief. The nurses and doctors there are numb to it. I don’t believe for 1 millisecond this is due to prescribed pain meds. What is really going on? I am treated like a sex offender because I have chronic pain and am prescribed Norco for it. And never in a million years would I sell a pill, or give it to a child or teen or anyone. I can’t express my outrage about all of this. I will NEVER forget the beautiful young woman, girl, who was covered with track marks on every vein on her body from heroin, it burnt a hole in me, and broke my heart. Lets get down to whats real. Anyone with me?

    • Dear Susan,

      I am with you 100%. I too believe they have it backwards and that it is their full intent. Legitimate opioids did not start the uptick in narcotic abuse but rather the increasing sums of heroin. “Funny” how the poppy fields in Afghanistan have quadrupled during the American occupation and how the aren’t being set on fire any more. Doesn’t this make anyone else wonder?

      I’ve read so many (“PROPaganda”), stories where people claim they never had any addictive behaviors or had never used a mind altering substance at all or in excess but when their doctor prescribed them 15 or 30 Percocet for a minor injury or post op pain and couldn’t get a refill they were forced to the streets and thus began their trip down the rabbit heroin hole.

      The powers that be have everyone scared p**pless that one pill and they’ll be hooked. The reality is that roughly 1% of people with no prior history of substance abuse and who take it only for their (worst) pain will develop an addiction. Some groups and people are claiming now that the studies done which yielded that result aren’t correct while they simultaneously cherry pick bits of negating information from this or that study, and their studies, to justify their claims. They want people to believe that over 50% and even 60% of people that use opioids are addicted or become addicted. But, the actual facts and science do not support their claims and yet here we are under a cloud of scrutiny and discrimination. Collateral damage left out with the garbage. Patients no one wants. Orphaned by the very system that was created with the idea that all men and women are created equal and have the unalienable right to the pursuit of happiness and as one would imagine that would also include the right to whatever means it takes to manage chronic intractable pain. But maybe I am just an idealist. Maybe it is too much to expect that my doctor, my partner in managing my health should listen to my complaints, my knowledge, my experience and afford me what I know works to abate my pain and the suffering that coincides… ??

      The idea that addiction is a disease leaves people suffering from it with a convenient scapegoat. Rather than taking responsibility they can blame something that takes all of their control and culpability. I once believed in the disease theory but now I am not so sure that even if it is a disease rather it’s a good idea to promote the theory. When people have their power taken away they act … well, powerless. To top it off our society has now set the stage for addicts to blame their overzealous (well intentioned or not), doctors. This has simply added fuel to the fire and caused those with addiction an even greater sense of helplessness. At least that’s my humble opinion.

      Please don’t misunderstand me, I have a lot of compassion for every single soul suffering from addiction of any type. I have seen the effects of drug addiction and it is utterly heartbreaking. I have seen children ignored, hungry and unbathed while their parents hit a pipe. I have seen young women and men die from alcoholism. Addiction is a serious problem but it is more than that … it is a symptom of our sick society. One that favors material things over the wellbeing of everyone but especially of the disenfranchised and marginalized.

      Addiction as a symptom represents how many people in our country live without means. They cannot afford a higher education. Jobs leave people J.ust O.ver B.roke (if they are lucky), and feeling unaccomplished which causes depression and anxiety. Opportunity seems to knock on only a few doors and those doors are usually ones where privilege already resides. Land of opportunity my A**! Not for those that need it the most.

      Government? Want to stop or at least abate the rate of addiction AND diversion? (again, not that I believe patient dealers are common). Give people the means to afford to live! Make housing assistance automatic when someone is forced into disability. Make fuel assistance automatic. Make at minimum an associate degree free! Allow people certificates to take their family to a movie once in a while. Give discounts for food, clothing, school supplies and so forth. Raise people up! There is NO shame in sharing wealth and privilege. Making people fight to just get by every day doesn’t build character it builds resentment, anger and depression…. which causes many to seek an escape. Start here and see what happens. Seems like a much more humane process than taking away pain medications from those that benefit from them and who cannot work, go to college, clean their homes or socialize without an adequate dose.

      Chronic intractable pain patients that have been abandoned and either forced to admit to being addicted have received grants (thanks tax payers), for a full ride through a $1,000 to $10,000 per nite drug rehab center. Who is profiting from culling the chronic pain patients? Just follow the money and you’ll be able to begin to put this puzzle together.

      I’m certain this entire campaign of misinformation has been salted with just enough half truths to make it seem plausible and to keep the public thirsting for more answers as to why Mr. and Mrs. Smith lost their teen to a heroin overdose, has not only been the brain child of anti-opioid zealots, but pharmaceutical companies whose opioid patents have run dry and wish to make billions more on another new and “safer” non-addictive pill for pain. And insurance companies, who at the onset probably believed if people were denied opioids they’d save tons of money but not realizing steroid injections, medical device implants and other non medicinal therapies would cost them much more, and stock holders of addiction medications such as Suboxone are also certainly involved.

      Seriously, I’ve never been prone to conspiracies but gosh … where there’s smoke there’s usually fire. This couldn’t be any more applicable to the current PROPaganda that’s stirred the age of opioid hysteria if it tried.

      Anyway, I personally HATE being treated like a criminal. Just because a small percentage of patients and doctors chose or choose to cheat the system does not justify treating everyone as if they are guilty and capable of committing a horrid crime against humanity! Maybe some people can sleep well at night without a care that their diverted drugs could kill another human being or keep a very sick person sick but I for one have no desire to sell my soul or to betray my physician for a few lousy bucks! Everything I have, have had or want to have in this life I have worked my fingers to the bone for and plan to continue to do (if I can find a compassionate doctor), for the things I want and need for as long as I live. Blood money has never appealed to me.

      We need a NEW patient bill of rights and we NEED it now! I totally understand the need for urine screens even though I find them completely degrading and unconstitutional but it’s not like pain patients are the only ones asked to take them. But what REALLY and SERIOUSLY gets under my skin are pill counts or “med checks”!! Forcing patients to submit to random checks, forcing patients to be available by phone 24/7 and forcing them to answer or reply within an hour is not only utterly cruel it should be against the law! It is a cruel and unusual and even draconian way to force someone to live! But alas, I have probably gone on enough for now. I actually wondering if all my ranting will be too long to post. Lol! Sorry about that but this topic really gets my motor running.

      A BIG HUGE THANKS to the owner of this blog! It was quite cathartic to write. I wish everyone peace and love – especially during the (difficult), holiday season.

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