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 ll try this again since it didn’t go the first one didn’t send. Who are most of the people behind this inhumane treatment of the people with chronic pain. It wasn’t enough for us to have a separate pain doctor. No they decided to cut some off cold turkey. And not the druggies. The will get theirs however they have to. But it’s senators, representatives, government people. Since when do these people have a degree in medicine? I thought they had law degrees maybe political science, they aren’t even required to take first aid. So how is it they are causing us such horrible pain? Excuse me what country are we in?

  • I agree. I was injured as a small child and over the years my lower back got worse. I am now 50 Dr’s had me on 150mg fentanyl every 2 days and 10 325 hydrocodone 4 to 6 per day for break through pain. I had a decent life still some pain but was able to do things with my wife and kids. Plus grandkids. After 20 years of being on these drugs my Dr up and closed office, leaving me with 5 50s 5 25s 5 12.5 no hydrocodone. No Dr’s now will help I did the injections had nerves burned etc. Now that’s all they offer so I let her try injections, now back is swelled I have no quality of life. Been bed ridden 2 months now and rather die than keep going through this. No government has the right to make me live how they think I should. Everyone I know who had severe pain are now herione users. I been offered and tempted but no it’s not for me. Is this what they wanted.? People will do drugs weather legal or illegal nothing the government does will ever ever stop it. People make stuff at home and sell it. Can imagine how high the death rate will rise for people who once did it the legal way. Now left with no choice but to have no quality of life go to a street drug die or suffer. The government needs to stay put of people’s business. We pay taxes that pay there salary. So by sense they work for. Me to so I say fire them all. You can’t force your will on the people. Just to save others. I never abused my scripts so why do I have to suffer the ones that did. It’s a choice some made the wrong choice. Why am I suffering for what I did right. Fed up with all this. Let’s see how your new law works. People just use street stuff with no idea what’s in it. Watch the death rate rise for people that once didn’t abuse anything simply wanting to live the best they could.

  • Visit the following link to send a message to the Government and file a class action suit against the entities behind this cruel behavior. They have no right to violate our HUMAN RIGHTS. Also report your treatment to the UN and anywhere online that allows you to FILE A HUMAN RIGHTS COMPLAINT!
    Request to start a class action suit and send a message to the GOV via the link below :

  • PharmCo’s have begun adding Naloxone to a few opioid meds to make those meds undesirable to addicts or anyone who just wants to get high. Anyone know if any companies are researching or
    developing more meds , like ones that are already prescribed and are already at least somewhat effective for people who take them? If docs & their patients have a treatment plan that’s been in place, there’s a relationship established. The doc should stand their ground, protect his/her patients and defend themselves in their ability to practice medicine. The more i think of it, the more unreal it sounds. Indiscriminate ceasing of opioids, no regulatory boards or agencies? Doesn’t sound like the US Govmnt. It sounds like a massive clusterfk panic. Is there no one who is monitoring? They monitor everything else.

    • Well, has anyone else thought about the people behind this whole situation, the govt and the individual Congress folks and reps. Govs. DEA, FDA,CDC,ATF, etc… how many of these trouble makers are qualified docters? I thought most of them had legal and political science degees. Are either of those required to take so much as first aid?

    • These Drs. are so scared, they have gone to large group facilities (that includes lawyers) to avoid malpractice suits. I’ve been dropped off of my panic attack medicine twice in the last three months, even though the 1st time it happened he said “I’m sorry about that it will not happen again” and he wants me to see MHMR . I am going tomorrow. He till refuses my medicine ( which by the way says “DO NOT STOP THIS MEDICATION ABRUPTLY!” ). So far pain managent has me on med. Through 10-13 which I’m scared to go there. But so far he has not told me a bold faced LIAR. And who can a person complain to? I was looking that up and you see where it took me. And I guess if I was rich I could go where the junkies go. Because they must not be having trouble, you don’t see any junkies leaving comments do you? Everyone is talking about their Dr letting them down. Because DEA, CDC, ATF, FDA and I know there are more because I’ve seen them. How often do we see this many agencies join forces to take our medicines away. I too am 60 and you can only imagine how I party it up on my medicine. What a joke. I never want to hear the phrase “First do no harm” ever again. This will not stop the druggies, or the overdoses, it’s most likely to cause more over doses and more crime than ever. I won’t be doing that because my life is not mine to take and neither is anyone elses. I guess I can go sit in the corner rocking back and forth and mumbling about what has happened. I just feel sorry for y family. Because they have done as much as in their power. I’m sorry for everyone who has commented on here, most of which I figure may have it worse than me. I will pray for all of us.

  • I’ve had a few serious accidents in my last 30 yrs of my life.Now in my 60s age,decline in bone health,I now suffer severe pain but only see my future to be that of only insanity,Chronic pain along with the hopelessness of the medical community that choices to fear governments new rules over the oath dr take” to do no harm”, knowing full well that some patients need an opiate to to help them to function in daily life to be a weight baring body in fighting the diseases that take over some young & older humans. Knowing these facts But never speaking out for these patients,Why? At some point of treatments that fail , how can you allow the abuse of older Americans? To force daily severe pain, until that patient has lost all hope in all dr.? If you go to many Drs. Trusting that you’ll get the care that is best for you,knowing that you’d never had a drug or alcohol problem in your 60 yrs Denying not from your history but DEA pushing these ideas that older should suffer,cancer patients should suffer,all because of DEA trying to make a name for themselves? While all along causing so much suffering in this country.Why aren’t there more Dr standing up for the patients that dr spent many yrs learing how to treat safely.It can be done & has been done,if only dr with proof(I’m sure there’s plenty of it out there) If these Dr would stop letting government bully dr & needy patients.Who else can if not Dr?

  • i was in a bad accident 2002, i’ve been on oxycodone for cronic pain since , being increased as time goes on by the docters as my condition gets worst. now they want to cut me off completely, what can i do , live in cronic pain basicly exsist with no quality of basic life. to me this is totally in human.. does anyone have any suggestions. please, tom beuth

  • I am now going through Fentanyl withdrawal because my insurance company will not pay for my prescription. This is NOT healthcare. I ask a couple things. Someone keep a list of those who died directly because of these new changes. Keep a record of the suicides. DON’T stop fighting! God forgive me for what happens next.

  • I am now going through Fentanyl withdrawal because my insurance company will not pay for my prescription. This is NOT healthcare. I ask a couple things. Someone keep a list of those who died directly because of these new changes. Keep a record of the suicides. Show that chronic pain patient’s are being made to look like addicts. Do NOT let this go. Lastly, God forgive me. I had a quality of life for four years. Now, the government took that away. My life is destroyed.

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