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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  • Been on pain meds 4 20 years oxytocin and morphine n oxcodones. Never fail a test n had 13operations n need 4 more. I screwed up did something i should not had did. Doctor stop pain meds at once. Now I’m going thru withdrawals. Help

    • Ronald Coleman. If you don’t mind. What did you do to have pain meds STOP like that. Please help me out. I done want to accidentally do the same thing. You can private message me thru messenger. My picture has me and my Dog. He has a white face.
      That is so sad. Another thing you can do is go to the hospital. Get some shots. I did. When I had out of control pain.

  • I contracted Acute Pancreatitis when I was 26. I am 65 now. I also contracted Diabetes Type 1 at that time. In the year 2000, when I was 46, I had 5x Bypass surgery with Staph Infection that lasted two years until the Dr’s re-sected and cleaned the wound. They did not want to de-bride it. I also had Moderate renal insufficiency and the chronic pain that comes with 38 years of Diabetes. Until the DEA put restriction on opiates I was fine. I am not opiate naive as I have been taking them fo over 10 years.

    My case is special as I cannot take any OTC, Ibufprofen, Tylenol or other “safe” pain meds because of my kidneys, so if I do not take morphine, I will be in acute pain all the time. I cannot get anyone to understand this catch-22. My pain management Dr is afraid of doing anything as my body becomes sed to the meds, so I basically have to go thru slight withdrawal every month before I get the next prescription. I could consider myself lucky that I am getting what I have, but I have a very progressive disease.

    When I take my pain meds, I can be social and be active somewhat This keeps the depression level down as well. I am concerned. I know the bureaucrats have no idea what they are speaking about when they draft all these new restriction, so I have to basically be stuck because of the triad of illnesses I have. Ibuprofen can put me into renal failure within a month. I can say and write all that I want and I have, but nothing does any good in just the understanding. I hardly get any sleep because I cannot sleep thru the pain. I even have a great support system,my wife, who keeps track of pain meds because one can forget their last dosage. To make it more miserable, the DEA/FDA has no idea who I ma or hoe opiate intelligent I am thru experience. God help us all.

    • There are so many in similar situations (maybe minus kidney issues with ibuprofen), for many of us Opiods are the only thing that works, and for some, its only one or two of those….. You have my sympathy, no one wants to hear us…..

  • Were can I find a doctor not afraid to prescribe chronic pain with debilitating disease. Had enough insurAnce company dictAting and doctors underpreSCRIBE OUT OF FEAr many people being cut off no alternatives its garbage . were. Tired of no solutions.

    • Louise, If you already have a doctor who was prescribing pain meds and is just afraid to increase them, don’t quit him. You will likely be more successful if you stick with your doctor and try to kindly reason with him. New doctors don’t want pain patients. Try to be calm and respectful with your request. I actually contacted a local politician who gave me advice from another one. And she said I have a right as a patient to have my pain treated! If I request that the doctor treats my pain, they have to adequately treat my pain. It is my right! I had a P.A. refuse my request, so I insisted on seeing a doctor in there. The doctor agreed I was on way to little pain meds. I have a condition that will continue to worsen, so my pain needs will continue to increase. Doctors need to understand this! Unfortunately some have been swayed by the opiate propaganda that is biased against pain patients! If your doctor is still not reasonable, then find out what hospital or clinic is over him, and then write a formal letter of complaint about them. let them know you are considering a lawsuit for failure to treat your pain effectively. The laws do vary from state to state, but most have clauses that allow the doctor to make the final decision. A lot of the doctors are now just plain scared of the government! They know that the more pain prescriptions they write, the more Big Brother will watch them. I actually saw one doctor tremble as he described his fear of the government coming after him. He must have been really scared! He has since left the practice for another state.

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