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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.

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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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  • Had a serious operation in 2012. Got a bad infection and was in intensive care for four months unable to leave bed. Had rehab for six months before I could walk well. Than had a series of surgeries to fix the related gut problems. Very serious pain but reduced oxycodone to 2 five mg. per day which I would hold off on until pain was overwhelming, usually after a day of so of semi normal activities. Then about 2016 after trying a series of dr’s. Gave up. So, no pain relief except my surgeons do allow 2 six hundred mg tylenols per day due to liver concerns which don’t do much. They’re ok with oxycodone for my liver but shifted prescriptions over to gp’s. I’ve gotten the impression that gp’s are afraid of losing their licenses. Guess this is why heroin, related drugs and fake pills are taking off, killing people. Maybe they should be dispensed at locales like abc stores to reduce abuse? Lumping people like me into abusers is not a good idea. Kind of difficult talking to kids about drug abuse if you’re one.

  • My wife uses over 90 milligrams of opioid s a month here in Texas. She does abuse these drugs but they are pulling them to get her down to 90 miiligrams. Her pain level is going to increase, there has to be an acceptance for some people. She had a stroke 4 years ago. When she was born her mother had MS, instead of her getting MS she got a bunch of other problems. This is not fair to my wife that uses these drugs as prescribed. I think this will increase the rise of unauthorized drugs now. They need to allow medical marijuana so possibly taking away some of thes
    e drugs. What do you do in this situation when my wife has bad chronic pain daily. Any suggestions.

  • I have been a pain patient for 16 years, I am inoperable, my damage is so extensive that without my prescription drugs I can not stand upright, I cannot move or care for myself, I cannot dress myself and I cannot even wipe my own button!!! _
    To take away my medications is inhumane and I have No QUALITY OF LIFE!!!
    I have never lost a prescription, I have never had any medical problems from my prescriptions and I don’t tell anyone I am a pain patient, and my medications in a safe!!!!
    This is not right to take my life away from me when I need them to live!! _!

  • It is time for us pain patients and our families to confront the CDC, DEA, FDA and our Senators and Congressmen and demand they step out of our lives as to how our doctors treat us and as to how much opioid pain medication they prescribe us. Nobody, not even our doctors, know how much pain we’re in or what doses of medication we need to control our pain so that we enjoy “QUALITY OF LIFE”. When I began treatment for my pain it took my doctor several months to determine how much medication I needed to enable me to continue to work and enjoy activities with my family. Once he did, my life was close to being back to normal. Now my degenerative health conditions have worsened to the point I can no longer work doing all of the activities my job required which does not include physical labor. I could still perform some of my duties but due to the substantial reduction in how much medication I receive that’s no longer possible. I literally suffer pain from my neck to my toes. Constant, never ending and relentless pain. I DO NOT HAVE TO SUFFER AS I DO if not for the limitations of how much or what kind of pain medication I receive. I already take anti-depressives and antianxiety medications for depression and anxiety diagnosed years before I started receiving treatment for chronic pain. Pain I had had for years before I set about seeking treatment for it. Ive gone through physical therapy, injections in my spine, non-opioid medications and none have worked. Im 56 years old and all i do is sit or lay on a sofa with a television on all day and night. I don’t sleep for days then when I do sleep it’s only for 1 to as much as 4 hours then either my pain or the PTSD I’ve been diagnosed with, wakes me and I can’t get back to sleep. I go to the grocery store and my doctor’s appointments when I feel like it and I’ve had to reschedule appointments more often than I can remember. My pain doctor is an hour away because she’s the only pain doctor that accepts Medicaid who had an opening for another Medicaid patient which said Medicaid I wouldn’t need if I wasn’t in so much constant pain. I would be able to find enough work that would make it where I could afford better insurance and could make a lot more money than what I receive from disability. If my doctor could prescribe me enough of the medication I desperately need then not only could I work but I could go to our trailer at the lake and go out in our boat, which is something I physically can not do suffering from the pain that I do. I wouldn’t be indebted to my 88 year old mother in an amount exceeding $100,000 which has broke her. The problems, pain and suffering, deep depression and anxiety, inability to go and enjoy my life and the inability for me to at least work part time would be eliminated if I could receive the amount of pain medications that I need to enable me to do all of the things I can’t do without them. We patients and our families have to fight for our doctors to enable them to practice medicine and treat us patients as they see fit. Us pain patient’s problems are not problems where “one size fits all” prescriptions will help us. We are at the very least entitled to have treatments available to us where we can have the best quality of life the IS available if government agencies would allow doctor’s to live up to their Hippocratic Oath and do their jobs as they and we patients expect to be available to us. God, please help us because our government agencies and politicians won’t.

    • Degen Baker, you’re totally right that this treatment of pain patients – basically human sacrifices in the war on drugs – is coming from bureaucracies in DC. The problem is that it is so much bigger than CDC, DEA & FDA. Check out this list of 35 federal agencies (many of which are duplicated at the state level), that are doing either war-on-drugs or promoting 12 steps ideology (including the idea that pain meds are so dangerous that they turn law-abiding pain patients into criminals seeking heroin for pleasure):http://truth0rdare.com/2018/03/13/us-gov-agencies-on-drugs-mission/

      Another problem is that the war-on-drugs has something for both parties, so there’s no credible opposition to this century-and-going madness of using the full weight not just of police/courts/jails but the federal government to try to stamp out a particular vice. The GOP can look “tough on crime” (meanwhile it’s a lot safer for a cop’s safety to bust a weed grower than a violent armed criminal, and pumps up the numbers of arrests and convictions), while the DNC can portray themselves as favoring treatment out of sympathy for supposedly diseased drug users (while using the power of prohibition to force people into treatment who are not so much diseased as violating a law against private behavior that does not target other people to hurt or deprive of property).

      I think we may need to make a stand by calling out both parties for their support of the draconian policies of the drug war. I mean if they have to go after law-abiding pain patients, that should be losing them hearts and minds.

  • I hate what’s going on in this country, so many good people being taken off pain meds when they shouldn’t be. I have spina bifida with thercord syndrome. Its a fatty tumor that have nerves all through it so surgery is a death sentence. I’ve been trying to get narcotic pain management because surgery will kill me and shots in the back is a big no no because it could hurt me ten times worse or end up hurting me down the road later on in life. Sadly this woman is an idiot she saw me twice before she asked me why I hurt. I’m like really after two visits you ask me this NOW? So I told her, doctors have been telling me for years why so I repeated what I’ve been told. She gave me attitude then said I want an MRI, X-ray and to see my old neurosurgeon who no longer does backs, he is a brain surgeon. When I told her he didn’t want to see me again for two reasons. 1 because there is nothing he or any surgeon can do anything and 2. Because he doesn’t do backs any more. When I told the pain doc this she said the dumbest thing ever. “I’ve never heard of a surgeon switching from backs to brains” I looked at her like SHE was nuts. The MRI just about killed me. Being on my back for 20 – 30 mins kills me my pains so bad. But I did it, then saw my old doctor. He told me not to bother with an X-ray won’t show shit. So I didn’t when I told him I was there because I’m trying to get my life back he was horrified that I was the shape I’m in. He told me I should be smoking pot. So he wrote my doctor a letter telling her to find something that helps me. So I go back Monday the 16th to see if I get any were if not I will be going to every pain clinic in upstate New York we need quality of life, depression is so bad because people with pain are depressed because of severe pain. They can’t sweep me under the carpet I’m 34 and constantly thinking about suicide because I’m in so much pain I can barely function.

  • I am one of those patients who involuntarily have had they’re hydrocodone eliminated. No if and or buts. In Jan. I was allowed 120 per month of 750. I am at this date allowed 45.,per month & probably less this month. I have never seen this dr. She does not know me. I have severe arthritis in my shoulders & knees. Here’s my catch 22. Drs told me the only way I’d get this med back is to go to pain management – ok, I’m going! From there they want me into therapy & from this I’m told- use a hot pack & take Tylenol. And try this ointment. I am 69 yrs old & I hurt! I’d like to do the therapy but it hurts to get dressed & drive 25 miles & walk into this place. All to get back pain meds that shouldn’t have been taken away. I did not abuse them, did not take them unless I needed them, and because my grandchildren (12&13) live w/meI always kept them locked in the safe. How do I fit in these new regulations? I hate being made to feel like a criminal by a dr who has never laid eyes on me. Where are my rights? What can I do? I’m getting more & more sedentary because I can’t move. How is this right? Any suggestions ? I am a patient at Rome Medical, Camden family care & the dr in charge of meds is Vivienne Taylor. Help, I’m getting more & more depressed.

  • I have two theories on why the drug warriors are targeting law-abiding patients with severe incurable pain: 1. The very fact that people like us consume large quantities of opiates (or opioids) while remaining law-abiding, not anti-social, productive (as productive as we can be depending on the severity of restrictions our illnesses put on our functioning) conflicts with their narrative that these drugs turn people into criminals. This narrative is constantly promoted by criminals who find this a very convenient out – in the 1920s criminals were blaming their bad behavior on alcohol. 2. Drug warriors (and their 12 step/ rehab “treatment” wing) need targets. If they managed to eliminate illegal drugs, they would all need to find a new job. It’s easier to turn pain patients into human sacrifices in the war on drugs.

  • Why do the severely injured people get served a life sentence due to druggies and dealers. I was on the low fentyal patch, i could sometime go 2 days without it. That patch kept me out if the E.R. Due to capillaries rupturing in my head due to migraines. Also diarrhea every other week for 2 – 3 liters if fluid because i was going into shock. But most important i have had 57 fractures, thats not talking about torn ligaments & tendons. It let me function with a level 6 of pain. Their is nothing that touches nerve pain. But it help me to have some quality of life with my grandchildren and church. Now i am bedridden most of the time.
    My freind has nothing but metal from waist down 53 surgeries. We both been guinea pig enough on crap that don’t work. She already talking about giving up on life due to the pain.
    What about our rights and our quality of life. We’re near sixty year old. We deserve some dignity.

  • Hi, Here i’am writing because i do not know what to do ? i had a work related injury and settled for life long care. I now have a Medtronic pain pump ( Lots of revisions ) using opioid pain medication for the last twenty years, yes a role model patient and now be treated like i am a drug seeking junkie ! NO, I am a person who had a back injury and left with spinal cord issues and needs opioid pain management to live some what a quality of life ? That’s all forgotten now and my pain doctors are telling me ” Oh well you’ll have to figure out what’s more important in my life and make adjustments ? I am a good person, father, husband. But, to go back to the living Hell of High pain levels ? I am asking for anyone who knows what i mean ? to let me know i’m not loosing my mind too ! Compassion seems to be lost as well ? Does it end like this ? Thanks for letting me add my two cents worth. Todd

    • I recently switched back into pain management after being treated by my PCP for 6 months. (I left the old pain management doctor when he told me he knew nothing about treating “my condition.” I’m not sure why the insurance company insists on me seeing pain management when they have nothing to offer me since all the clinics on my plan specialize in spinal pain.) Anyway, the new pain management doctor told me that her life “was fulfilling without children,” so her advice was to have a hysterectomy now instead of staying on opioids. Really? None of my THREE treating physcians recommend another major surgery right now and fertility is important to my partner and me…to top it off she accused me of lying about my morphine prescription because she pulled the wrong CURES Report!

      I get frustrated because I can’t say to the pain doctor, “I honestly might kill myself if my dose gets lowered because being in constant level 10 pain is not sustainable.” That’s how I feel, but then they treat me like an addict if I say something cataclysmic like that…

  • I cannot thank you enough for giving a voice to millions of us who are suffering from either being “weaned” off, or suddenly dropped off of our needed medications. Even after years of being well regulated by our pain doctors we have been suddenly dropped by insurance companies and told we will be unable to have the necessary pain medications that allow us the quality of life that we desperately need and want. Insurance companies are using the CDC regulations to twist the wording to their benefit, as a reason to eventually drop patients off medications. With the government and medical foundations to back them, they are able to save millions of dollars. I have lifetime disability due to an accident at work, granted through the courts of CA. The insurance company that handles my case is mandated to care for my needs, yet they are using the CDC as a reason to eventually take away my pain medications completely! I am a model patient that never misses appointments, always passes any drug testing, and am clear headed at all times. I have a very good pain Doctor that I have been seeing for over 8 years that states that I am one of his best patients. I don’t do this for the doctor, I do it because I would like to enjoy my life and my family for as many years as possible😄. Thank you for supporting us in this battle. Peggy

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