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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    • File a complaint with your State Board of Medical Examiners, asking that the doctor who has deserted you be sanctioned for patient abandonment. If you can’t afford a lawyer to inform you of how to get your complaint heard, you might try the nearest office of Legal Aid. Most large cities in the US have one.

  • I have been on strong opiate medications for about 7 years, roughly estimating. I have never overdosed or abused my mediation. I developed pain that lead to rheumatoid arthritis that is heriditary in my family. As a medical professional, I am appalled and not including terrified of having the medication that makes my very life tolerable to live. These strict and new unfair laws, limiting opiate medication use is very and irresponsible and dangerous. I believe that all there doing is creating a new problem. As chronic pain patients and others on these medations will have three alternatives. One, turn to heroin, two become a useless bedridden individual , or God forbid, commit suicide. I believe this should be looked as a individual case to case situation. Why should responsible chronic pain patients be made to pay the price of those who don’t use their medications properly ? Someone has to speak up for us responsible chronic pain mediation individuals. I’m am a good single parent of four children and an honest law abiding citizen. I find myself now being looked down upon not to mentioned stigmatized ! I’m am highly disturbed and want to to do something about it. I don’t know how, but I will find a way to advocate for my fellow chronic pain patients.

    • I agree with you 100%… I too am in the same situation as you, I have been a model been patient for years, and was awarded Social Security disability for reason after working many many years.… I don’t understand why our pain doctors don’t have petitions for us to sign to take to our local congressman, governors or something?? It doesn’t seem like they are worrying about us at all, every month since January I going to the office jump through all of their Hoops, and my medicine is drop down every month and the next two months I will be at the 90 morphine equivalency, but I have heard that they are going to continue to drop or levels down this is insane the stress it has caused me Makes pain worse…my blood pressure is through the roof every time I go into their office, and I tell them it’s because my pain is so bad now I cannot hardly do what is expected of me from my family and unfortunately I am a grandparent who has been left to take care of two small grandchildren who do not understand why their grandma can’t hardly do anything anymore I live in A small town in Arizona I wish something could be done… Any advice out there ???

    • I must say that i have been on pain medication for almost 20 yrs. With the same dr for 15, and the same dosage for 5 years. I take my meds like i am suppose to and dont appreciate the fact that i will be one of the people that will be bed ridden or commit suicide because i refuse to try and just deal with life and be in severe chronic pain. I dont drink or do street drugs. Or play these stupid games with pills. I did not ask to be put on these meds, a pain dr started me on them. I already have a very low quality of life and if Jesus is not going to take me, i refuse to suffer. Ive been thru spinal surgery in 1999 & 2000. I have nerve damage in my arms, 11 herniated disc, lumbar radiculopathy, degenerative disc disease, fibromyalgia, arthritis, stenosis, myelopathy, and its only getting worse the older i get. I have a lung condition, stomach condition, had an umbilical/abdominal hernia repair in 2006, and now my vocal cords have a problem too. My entire body hurts every day while taking a high dose of meds. And now im being told that i have to spend $100 of my $755 check to keep taking my meds. I have to pay for the muscle relaxers that agree with my body. I think it is utterly disgusting that honest law abiding citizens that try to live a decent life with integrity am being forced to kill myself or break the law. I know for a fact that i could drink and do drugs and not have terrible pain. What has happened to our civil rights and the ADA. Its bad enough that i have to live in a dump of a mobile home with slumlords that own it. But i refuse to lay in bed and suffer like hell because some idiots that dont have a medical problem can limit my pain med intake. I take my drug tests and pass them. I have not been high on my pain medicine yet. Why do they even make it? Is this medicine not made for PAIN. NOT JUST AFTER SURGERY PAIN. NEXT THEY WILL BE MAKING US HAVE SURGERY AND BE WIDE AWAKE. WOULD IT HELP THE OPIOD PROBLEM IF I SOLD THEM JUST TO PAY FOR WHAT I NEED. OR TRADE ONE KIND FOR ANOTHER? Hell no it wouldnt!!! It will only add to the problem. If the people that are making these laws had to deal with what i do on a daily basis, i bet they would change these laws. Im just appauled that because i have severe chronic pain im being looked at as a lower class citizen. I am almost 59 yrs old, i was in a car wreck at 17 and now im paying for it. And its a down right shame that i have to fight in order to just be a decent person. My nerves are shot from this stress thats been put on me by this mess. Its unfair, its ungodly, and absolutely makes no sense. Maybe its time that i just take my screwed up life and give the air i breathe to someone that sells heroin on the streets. Ive never seen it. Ive never put a needle in my arm. But i would be better off if i was just dead. My father spent 20 yrs in the air force. The first 16 yrs of my life. And i have to end my own life because my country could care less if i live or die. How damn sickening is this? I refuse to lay in bed every day and suffer because other idiots abuse the meds that i need.

  • Cindi, I have no idea why tramadol should even be limited. It’s not an opioid but for some reason, they lumped it in with opiates which makes me wonder if this really is a ploy to undermine pain patients in general no matter what meds they take! Makes absolutely no sense that tramadol is limited.

    • Luanne, they are limiting Tramadol because it has been in the system of several people who have overdosed recently. It’s not dangerous in and of itself. Again the problem lies with addicts and criminal behavior, buying Tramadol without prescriptions, mixing with Alcohol, Xanax, other strong pain relievers, then people get upset when they stop breathing due to stupid choices.

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