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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  • What I don’t understand is why are there ppl that still get the same meds that they have been on for yrs that are above 90mme and some are forced down to 90 mme or less ,they aren’t doing or have cancer and don’t see shady doctors.I just don’t get it! Do they see doctors that just say screw the DEA,or do they have a deal worked out with them?Don’t get it at all and I am very well versed on this so called opioid epidemic.

  • I was taken off Norco for chronic pain and was prescribed another opiate that was a once a day time released pill. My insurance did not cover it. I suffered horrible withdrawals, worsen Deppression, suicidal thoughts, terrible hot flashes and sweats diaraha. Cramps. All on top of pain. I have never misused my pain medicine. My doctor finally put me back on Norco. I am feeling much better. But this was unnecessary suffering.

  • Thank you for greater is He that is in me! Yes it’s true. I believe that is all that has kept me this far. I remember being in so much pain that I was almost unconscious. I’ve gone to the hospital a few times I don’t really know how many. I don’t have Lyme disease. I’ve had juvenile arthritis since I was about 16. It’s that I’m 62 now and yikes. Thank you for the scriptures it really helps.
    To Christine Gavitt. Aman

  • Well I’ve been following the comments for awhile and looks like to me that even tho it’s good to vent NOTHING is being done. We cry but our tears are not wiped away.
    I spent another terrible night of pain. I already don’t take enough to stop my pain only enough to take the edge off so now I’m told that even that must come down. I used to dwell on suicide quite a bit. I KNOW I’m not the only one. My insurance will not send me a house keeper even tho my doctor wow a script for it. So now what?
    Hate living, scared of dieing.

    • Ronnette, I hear your frustration! This whole mess came out of the need to blame someone for all the opiate deaths. They pointed the finger at the doctors, and now they are running scared! But the real problem is the drug addicts who also blamed the doctors for introducing them to pain relief. They need to take responsibility for their actions and quit blaming others for their lack of self control. I know the feeling of being afraid to live in pain. We all know what our options are! But you are stronger than those drug addicts! If I may share something here that won’t get rid of your pain, but it might help you keep your sanity through it all. It’s the words at Isaiah 41:10

  • Here we go again…CMS/MEDICARE Part D is under attack. For their “Proposal” in 2019 they are trying to MANDATE the CDC “Voluntary” Guidelines. Implementing a 90 MG (MME) Morphine Equivalency. Meaning no one in Medicare Part D (excluding only cancer and hospice patients) would be allowed to fill their opiate prescriptions for anything greater than the 90 Mg Morphine Equivalency cutoff. I cannot even Fathom the pain & suffering these people will endure due to this strict mandate they are trying to implement. It is “inhumane” and further more “Reckless” to impose that this “one size, one dose fits all” approach be the standard of care for ALL pain patients. Managing pain doesn’t work this way. There are so many different “Variables” when trying to manage an individual patients pain, one could not possibly say that this “Dose” will work for everyone. Yet, time & time again it is being FORCED that these CDC “Voluntary” Guidelines be Implemented for ALL. Wrong. It is so wrong in fact that those “Guidelines” were created and wrote by addiction specialists, and groups like PROP who are very CLEARLY against opiates in the first place for managing any pain that to put the “Guidelines” to be wrote by their hands…Should NEVER have happened. Those people are BIASED and that is the nice word I will use for it. Their “input” shouldn’t have been allowed, let alone giving them the “pen to write it”. Something needs to be done here. I have sat by for YEARS now and watched as the Pain management “pendulum” has swung so far out of sight now that we have crossed the line to the treatment of pain patients into Medical Negligence, Neglect, Malpractice, Inhuman treatment, and Severe Suffering that is being put upon these patients day in and day out everyday across america and the Physcians are being told oh, well…turn a “blind eye” to it and keep it moving…nothing we can do…yes, most Physicians will say it is “WRONG” but what can they do??? Well, we need to start “Somewhere” Right??? To stand up and fight for what is right? To stand up and fight for these patients and their right to have pain care? For their rights to have “opiate medications” for the treatment of pain, that cannot be well controlled through other modalities. We have entered into an outright “PROHIBITION” on opiates. We have learned from past “prohibition” it DID NOT WORK RIGHT? What has history taught us? That when one thing is “taken away” it either goes “underground” OR a new substance takes its place…Well, BOTH things have happened here…opiates have been taken away so now we have ILLEGAL Fentanyl, and Heroin use that is RAMPANT. People who WERE law abiding citizens went in search of finding their pain care on the streets because it was taken away in the Drs office and their quality of life was taken as well. So people are dying in droves so what is the answer??? Oh, Right…More restrictions, tighter laws, take it away from more & more people creating even more “demand” on the illegal black market. The Cartels are loving this, eating it up…While the sit back and collect their hundreds of Millions of dollars in sales While America says “Look at this Opiate Epidemic!!!! Tighten down the access to Opiates more! We have to get this under control!!!! Well, it hasnt worked, NONE of it has worked. We still have overdose deaths, but now those overdose deaths are growing due to illegal black market Fentanyl and Heroin. It’s done NOTHING but rip pain medication out of the hands of the legitimate patients hands who had a right to have it and people are STILL dying because they are going after the WRONG people and have went about this the WRONG way completely and they continue on this path…now CMS/MEDICARE says Look, look at the numbers of Part D Beneficiaries that receive an opiate prescription!!!!!!! OK, WELL MEDICARE has a VERY diverse group of people. Who is Medicare FOR??? OH, YES Seniors and the Disabled. So, looking at WHO needs these medications may help them to understand why their is greater opiate prescriptions in the PART D program. These are senior citizens who as they age have progressive painful diseases of bone, joints, etc and the Disabled…well, they have complex variety of pain issues in and of themselves. It isnt because the PART D program is Rampant like they are trying to make it seem with drug users and abusers…these are seniors and disabled people who if anyone have a greater need for opiate type medications. Medicare doesnt seem to understand this. So, the answer??? Take it away. FORCE Dose Tapers on these people effective 2019. Make these people next on the list to inflict inhumane pain and suffering. 90 mg MME Morpine Equivalency MANDATE FOR ALL. Many of the patients in PART D are on doses greater than this. Not because they are abusers of these drugs but because they have been on them long-term and their bodies are tolerant, because they have often complex pain issues, a range of degenerative diseases…etc. If you force these people into withdrawal and get them to 90 MG Morphine Equivalency how well do you think those doses will work to control these patients pain after having been on greater doses for many years??? Well, its not rocket science but maybe they need to do a study on that so THEY can understand how these medications “Work” for the treatment of pain. If 90 Mg MME Morphine Equivalency worked for them, then they would already be on that dose or under it. I am sickened on a daily basis about the treatment of these patients. The government, Senators, FDA, DEA, FEDS, CDC, THEY NEED TO GET OUT OF THE EXAM ROOMS PERIOD. These people DO NOT HOLD MEDICAL DEGREES. These people do not understand the consequences of their actions. They do not understand what they are doing to these patients because they do not umderstand these MEDICATIONS or the treatment of PAIN. Yet, they are the ones telling doctors what and how much they can give of medications???? How and when did this become ok in America??? Its like bringing in a government official and handing them the tools used to do brain surgery…Would they know what to do??? No, because they arent TRAINED. Yet. We can put Pain Patients medical treatment and care in their hands and thats OK??? These “Opiate Medications” dont work that way to say Hey, This and this DOSE ONLY of ALL pain medications is to be given to ALL pain patients. ONE DOSE FOR ALL. This shows these peoples LACK OF MEDICAL KNOWLEDGE AND UNDERSTANDING OF THIS CLASS OF DRUGS. Why in gods name have they been given the power to DICTATE DOSING ON MEDICATIONS THEY KNOW ZERO ABOUT????????? THIS IS PURE INSANITY PEOPLE. Its time, time to stand up. Time for this to be taken out of the Governments hands and given back to the Doctors. I think CMS/MEDICARE is going to be looking in Pure & Utter Chaos if they implement the CDC GUIDELINES into their Part D programs. Hundreds of thousands of Seniors and Disabled people will be turned away at the pharmacy empty handed creating a MEDICAL EMERGENCY for these patients many of who cannot be ripped of these meds or reduced due to complex issues. Which can not only be dangerous for these people but can become deadly. I cannot beleive that CMS/MEDICARE would even be considering this in their program…..its the wrong group of unique patients with many health challenges to be doing this too…I SEE A HUGE CLASS ACTION LAWSUIT ARISING AGAINST MEDICARE….they may have been able to put these mandates on “Medicaid” but Medicare is a whole different ball game…one of which should NOT have opiate dosing limits implemented on them. “May God help these people now”. #PrayforMedicarePartDBeneficiaries

  • I too have had 2 failed c spine fusions the 1st one was in 2000 and the 2nd was in 2011. I have been succesfulling in managing my pain for the first 10 years with 2 to 4 hydrocodone 7.5. After the 2nd my pain became much worse but still managed with 3 hydros and 1 30 mg morphine to help sleep. When my pain would get bad my Dr would switch it out and try 3 2mg dilauded and 2 morphine then when I could get it under control again I would go back to the lighter regimine. Like I said that is pain management like these doctors know deep down. I raised my son and did get disability but also managed to work and take care of the house and be there as a single parent for my son. My pain management dr now is only allowing me 2 hydro codones a day. I have now in just a short amount of time can no longer work, I can no longer take care of my house and I can barely take care of myself. I am in horrific pain those 2 hydrocodones are not even relieving my pain for a couple hours a day. I am exhausted because the pain will not allow me to sleep. I also have degenerative disc disease. The pain is all consuming I hardly ever leave the house and have no joy in my life. I am deeply depressed. I can not breathe because the pain around my ribs wont let me take deep breathes and my lungs fill up with fluid that it hurts too bad to cough. Im treated like a drug addict if I even try to ask anymore. This town is monopolized by 2 main dr offices and you can tell these dr’s are like puppets guided by regulations that frighten them of losing there license so they wont even try to stand up for people like me. In my opinion this is murder. You have decided to kill me and not only that without dignity and suffering horribly for the rest of my life. All because some people have had the choice to OD. I do not get a choice. And believe me the ones that OD are certainly not only taking medications but they are the ones stealing others peoples medicine and taking other illegal drugs, they knew there was a chance doing what they were doing. The dr’s never killed them with the prescribed amount they killed themselves by abusing drugs. Dr’s are not being sued because they are dying. This is just another way for the government to try and control peoples suffering. Yes more people are gonna die now because people in pain are going to have to find other drugs or any means to help try and stop their suffering. Alot of people will be commiting suicides now because we know we are going to suffer miserably worse and worse every day with no help from no one. We are going to be flocking to the few assisted suicide states . Haven’t you realized the more you try to control our freedom to not suffer and the choice of what to put in our bodies there will be so much crime people will be killing each other to take wharever someone does get from one another. People will be doing all kinds of crazy things and this is the fault of those that are enforcing these changes. We no longer have the choice. I sure and the hell hope there will be billions of dollars of lawsuits filed for this inhumane action. Literally the best thing to do would be to make the prescription medication readibly available to anyone who asks. If people then choose to abuse their meds and died it was there choice and nobodies fault than their own. I guarantee you any person suffering would gladly sign away any legal obligations on the health care system to simply have the choice to not suffer. Its that simple. PLEASE HELP ME!!! I want to just make the best of my life and not suffer and pray for death every day…..PLEASE I BEG YOU

    • I would just tell your doctor point blank that the new doses are not working at and that you can not function as a human. Tell him you are not asking him to kill all your pain because that is impossible, but you want to do more in your life than lay in be and only get up to go to the bathroom. Tell him even that hurts too much to do. Tell him your next stop is going to the ER because you can not and should not and you will not live like this. Say you could function before but not t all now. If he is afraid of OD then put you on the extended release versions of your meds which are made so you can’t abuse and OD. Ask him point blank if he still wants to treat you if not tell you so you may find someone that will. He works for you and makes good money doing it. The doses you take now are barely enough to stop a headache let alone back pain. What State do you live in? Living in the pain you describe will shorten your life greatly. I’m so sorry.

  • I have a restricted Lung Disease caused by nerve damage to my thoracic area and now my diaphragm. My pulmonologist is very upset because the Fentynal Patch that I have been taking responsibly is now giving me my death sentence, the pain center I go to treat me terribly and I am on 4 liters of oxygen, so I asked if I should just take off my oxygen and let nature take its course and she responded “That’s up to you!” As if to say I would be one less burden for them. I had been going to the same pain clinic for 5 yrs and instead of seeing my doctor, I seen a PA who tricked me into signing a new commitment form before saying I will be taken off the patch and put on oxycodone that I’m allergic to, he would not let me explain anything except to sign out which meant I could not return. Now the other pain center that doesn’t know me From atom is treating me like an addict, I had to go into withdraw with no one to offer any kindness. I have lost all the cushioning in my neck and have a significant bone spur pressing into my spinal cord, and I am seeking a neurosurgeon that will do the extensive surgery using the hip bone after I have a mylagram on the 26th. I need help because the patch helped me to have some existence and now I have nothing except my pulmonologist and psychiatrist who treats me for PTSD. I have had several people in my life who have tried and almost killed me including a nurse in 2005 and a doctor in 2013. Both ACCUSED me of overdosing on my pain medication. The first through me out of ER, and I had an ear infection that went to my brain, my BP went to 48/40 and went into septic shock, my doctor had just walked in the door in time to save me three days after I was kicked out while this same nurse tried to kick me out again. The latter had came to the same conclusion when I had stopped breathing in my sleep, what he failed to recognize was car second car accident had further damaged my chest wall and diaphragm. I went unconscious a second time and he kicked me out of ICU took off my oxygen and took out the regulator from wall and left me to die my saturation went down to 67 before a patient advocate ran in to put me back on oxygen. NOW again I am being treated the same way for being a responsible adult who is caught in the middle of the red tape and this is signing my death sentence earlier than I would like. Can you help? I am desperate. Angela J White

    • Fentynal I’m afraid is a thing of the past. They are eliminating it from the marketplace so that hopefully stay off the streets where people are mixing it with heroin and dying. Pain doctors cannot prescribe it anymore, so they have to find a new med to take it’s place, the most popular are extended release morphine and extended release oxycodone. Allergies to these can happen and they say that with an antihistamine (like a Benedryl) candy be prescribed to help with any reaction. Good luck but Fentynal is a dead issue and I was on it for 10 years

  • I had 2 failed back surgeries 17 and 18 years ago. My pain doctor at the time had me on 30 mg Oxycodone, worked up to a 100 mgh fentanyl patch, I came in one day and was give coupons for Actiq he started at 400 mgh and quickly had me up to 1600 mgh Actiq. Needless to say my pain issues were better I was able to to work a high pressure corporate jop managing several sales agents. The Actig came to an end after 3 months receiveing it with free coupons. After my second back surgery my pain Doctor dropped me. I found a doctor that took over my care. After several test and learning my history he prescribed the same mess, at this time Actiq had a generic and our insurance paid for 4 boxes of Actiq, I was also prescribed 120-35 mg Roxicodone, and 100 mgh patches. This had become my baseline and I was working a high pressure management position earning a good living and being active in church and other activities with my family..this went on for 15 years. I want to add I saw my pain management Doctor every month, he gave me a though exam, DEA urine screen to be compliant. Last year I made the decision to drop the Actiq and start a taper. My pain steadily increased and my body and mind field worse with the taper. Last month I underwent the worse back surgery of my life, I have degenerative disk that’s very painful. My pain Doctor has reduced me to a 50 mgh patch, with 15 mg Roxicodone at a reduced amount I am in pain, depressed, have lost 20 pounds mostly bedridden certainly can’t work. When my back surgeon did my second surgery with a 2 vertebrae fusion he recommended getting disability, I was to proud and was successful for 20 years. I’m afraid if our government doesn’t allow doctors to recommend and prescrib the proper medication to keep us working I’m afraid a lot of long and short term pain patients will suffer and die.
    I always wondered if Obama Care encouraged opiate use to keep operating cost down.

  • My pain mgt told me today that they are going to start bringing my oxycontin down from 20 mg two times daily to 15 mg two times daily to 10 mg two times daily. Over a period of three months. Plus I can have six 10 mg hydrocodone daily. I already went From 10 mg to 20 mg oxycontin and I am stable. If they lower my dose I’m going to have less active life. Help me please. I don’t want to die from sadness. I get like that from the pain. I don’t want to give in to the sadness. Can you help me. I have a disease that is deteriorating all my joints. ALL of them! I’m so scared. My dog had the same sicknesses that I have now. I don’t want to die like that. I want to be comfortable as I get sicker. I don’t want a pain pump because I have trouble with infections. I get steroid injections. Sometimes they don’t work and I have to wait for seven months till I can try again. I’m really upset. Surgery won’t help. To many joints involved.
    Thank you for listening.
    Oh and I’m 62. I’ve been sick for almost 20 years. Been on opiates for about 8 years.

    • Wow you sound exactly like me and you Disease sounds like mine also. Make do you and did you dog Have, it sounds a lot like Lyme Disease. If you want contact me and we can compare notes.

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