Amid 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 am one of those patients that is suffering because some idiots abuse pain pills. This is not a guideline when pain management physicians will have their licences suspended if they don’t comply. They have made it impossible for the doctors to help their patients. Maybe the insurance industry started this in an attempt to kill off all the disabled people. I am sure we cost more than healthy folks. Someone please help us. We are living a nightmare of pain.

  • Keeping it short because I’m in hot pain. Disabled, chronic acute condition and no cure. State made threats to hospitals, not wanting the legal heat no opioids are prescribed, dry spell. In my case this was the regimen for pain as well suicidal ideations. Only option given is nerve blocking. Condition in my case denies me treatment as surgical wounds turn into abscess. All patients whom were prescribed opioids had there personal information collected and released without notification or consent to any parties. All mandatory drug rehab regardless of condition or if abuse of meds even present. We need help in Appleton WI, please.

  • Dr. GAJDOS on Clifton ave in Clifton, NJ has been giving my sister opiod’s and vicodin for over 10 years. She has has a few strokes. My sister doesn’t eat 1 full meal a day. And of course these drugs without food is affecting her mind and body moreso. Her DR. doesn’t show any concern of her not eating. She is like a skeleton. She has no physical strength and can’t concentrate . The most recent time she was in the hospital he told her just keep taking your medication. This DR. is going to be the cause of my sisters death. He shouldn’t be able to have a license.

  • Please do not let the pain win by taking you life. I too suffer from an incurable chronic pain disease called arachnoiditis. It is still a rare an orphan disease. My doctor told me to get heroin and use it then go to the methadone clinic because drug addicts don’t have rules they will increase and increase until you are comfortable. I had to use Methadone when I was pregnant in 2002 because it is the ONLY pain killer that cannot cross the placental barrier. He was born 7 weeks early but not because of the methadone but because I was way too old to be having babies. Just don’t give up

  • I’ve been an chronic pain patient since late 2003 when i broke my neck in 3 place’s.left my left arm damaged in very great pain still today,i’ve tryed about every treatment with very little or no pain relief,only opioids in mg’s,amount that won’t be given to me now,for it called everything but pain relief,and that i guess is to shame base an person like me so bad,that they just want to go home and die in pain so great no human being,that if i was a dog they buy me my own house,but since i’m human and the only thing that helps is opioid doctor order pain medicine they give to me in so low amounts and mgs they don’t work not an drug addict,i will not even call myself disabled for you have to be able to move to be disabled,this is ungodly,unamerican,just plain wrong in the eye’s of god and man,i tell you,it going to be the lord they see on judgement day for torturing and killing real chronic pain patients,i pray they willrepent,but have been asking them for years its hard for them to believe in GOD when they think they are god,iwill take lie detector test everything i spoke is the truth,i’m not an drug addict,just an patient in veryy great chronic pain,who’s opiod rx pain medicine worked till it was reduce in amounts and mg’s till it stoped my life,haven’t kill myself yet,but i sure think about it to end this great suffering and torture i live in every second,thank you dennis lawson.

    • Doctors are not God. You are important. It continues to trouble Dr Gordon and myself and many other professionals that this is happening, and we are continuing to speak out.

    • Dennis, It’s horrible this epidemic of genocide using restrictions that will and are killing people. I have chronic pancreatitis and hemochromatosis. My pain is excruciating as well, and is progressive. I have only continually been reduced in pain meds even though my initial dose was a low dose for the conditions I have. I understand what it’s like to try and keep your chin up despite the inhumanity. I hope that lawyers can at least find giving advocacy for people like us profitable, because I fear that will be the only way things will change. I see even cancer patients being treated like criminals and druggies. They can not complain about the way they are treated or else the defamation will pursue. I overheard the staff at my clinic talking so bad about a terminally ill patient, with the pharmacist. All the patient wanted was her doctor to call the pharmacy so she could have her refill approved to fill one day early as the doctor said he didnt mind if she needed him to advocate for her. I guess he actually did mind, and as a consequence she was treated horribly for requesting his assistance. I have to pretend to be happy when Im at my appointments because then at least Im likeable and that’s the only thing that saves me from being totally blacklisted. As I’ve seen what happens to those they lable as such. I am constantly expected to go through injection procedures that do nothing and my pancreas doctors would rather I didnt, but the pain doctor believes it’s helping when it’s not. It actually exacerbates the tenderness in the pancreas area, but I fear that if I refused then meds would be refused. It’s almost like a dysfunctional relationship one has with their pain doctor. You anticipate the abuses and plan accordingly. It’s pretty bad once a doctor can advise a patient to do heroin for help with methadone because that’s her only hope for pain relief. Anyways, I just want to say Im with you and understand what it’s like. It’s horrifying reality. To feel like an abused dog, but we are just human’s, and therefore hope seems diminished. However, I do hope that you don’t give up hope, and keep seeking any alternative you can find, as I do the same. Keep speaking out tell your story, because perhaps someday our words will matter. My regards to you and everyone else who is suffering. X

  • I love that fact that a suit in an office gets to decide my pain level for me. All of the opioid related deaths were OVERDOSES some of use use our medication properly we never run out before the end of the month or test positive for other opiates on our drug screens. I have arachnoiditis yes google it it is a rare and orphan disease of the interior of my spinal cord. It hurts all day everyday kind of like being in labor 24/7 forever no treatment except pain medication and no cure no surgery to make it better no any hope. 75% of all people male and female commit suicide in the first year and I understand why life sucks big time with this chronic condition. Oh I forgot the best part I got it from the pain clinic doctors and their 42 depo-medrol epidurals to ease my pain from ruptured discs in my lumbar spine. No they NEVER EVER SAID ONE WORD about arachnoiditis. If they had told me I would have run for the hills. Even on 150mg of morphine a day it is still unbearable. I get the extra 60mg of morphine because it is a rare and orphan disease. I usually spend most of my time with a pain level of 7 or 8 however when the humidity is high it is a nine I will vomit pass out and I feel terrorized at a 9. I never say a 10 because I have been told it gets worse have to save my 10 for when the pain kills me. I am ashamed of our government how can they tell what elevates our pain. My husband is a doctor and we get drug seekers all the time. Listen up FDA a drug seeker will request a certain drug like nothing ever works except Lor-Tab 7.5/750 of dilaudid. They always run out or it was stolen or they dropped it down the sink or their pet zebra ate them. They will lie cheat steal threaten you and I always tell them you are exhibiting drug seeking behavior and request the go to a local in patient treatment center. Them I am a bitch and they are calling the ADA THE MDA THE ACLU THE ATTORNEYS GENERAL ETC. I think the doctors are able to see this but for those of us that really hurt we can’t fake the high blood pressure elevated heart rate the profuse sweating the tears are real FDA. My doctor is smart enough to see that he went to school for 12 years 3 year residency and some another 4 year fellowship. They see me not an epidemic of drug abuse the doctors don’t hand out Vicodin like tic tacs. The heroin addicts have zero guidelines on how much methadone they can have up to 300mg in a clinic I used to work in just for the non medical trained 80mg of methadone is equivalent to 640mg of morphine. If your an addict your okay,but God forbid you have a real pain problem you can’t be trusted. This situation is so f****d up it’s ridiculous.

  • I Also I am a chronic pain patient, and worked my whole life, and am now disabled. I have many incurable diagnosis, I try my best to care for my two grandchildren while my son works. Every month I have to jump through the hoops at my pain doctors office, and every month my pain medicine is greatly reduced, the amount of pain meds I’m left to be on right now is unbearable… The emotional, mental, and physical stress is worse and worse on a daily basis, I wonder about who will be left to try and take care of these adorable children, It’s harder and harder for me to even try and function and get out of bed, my son needs to work, we can’t afford day care… What a way Exist. Those who continue doing illegal drugs don’t seem to have a problem getting their Drugs, it’s not fair. I have been a model pain patient, I have never missed an appointment, never missed a copayment, ( my office would refuse to see me i did not pay, I have to have that $40, or I would be left with severe withdrawals because I would not receive my prescription!!!! it’s all about the $$), never had a dirty urine test, only use one pharmacy, have to fill out a questionnaire each visit, it’s absolutely ridiculous…Every month they go through this routine it’s like, they are trying to find one thing wrong so they can fire you… I know they are trying to cover their butts, but it doesn’t seem like they care… They ask you what your pain level is… What does it matter?? They don’t change your medicine, they don’t give you more medicine… the patient’s well-being doesn’t matter anymore ..I have been a model patient but yet I am under the looking glass!!!!! Doctors just take medicine away every month, and expect us to keep on doing everything expected of us, and keep going about like nothing is wrong when it’s killing us every day slowly. I Feel we pain patients are being tortured…Something has to be done to stop this madness, and quit punishing the chronically ill suffering pain patients !!!!! I don’t know how much longer I can continue, I have to use my walker now sometimes, And when my son gets home, I’m in bed, I am No longer living my life, I am just existing… I have evicted from my life!!!!!! PLEASE!!! Before it’s too late, and the suicides continue for the chronically and Terminally ill patients, that just wanted to live the rest of their lives to the fullest means possible, Those of us who use medicine to live With a little more comfort, because believe me my pain medicine helps, but I am always in pain, those of you who suffer know exactly what I mean… Lord help us all !!!!!!

  • I am a long term chronic pain sufferer/patient. All of my pain medication has been taken away, & i can’t EVER 8se NSAID meds due to a perforated intestine from an ulcer. Basically, I’ve been told “Too bad, so sad for you”. I’ve tried everything possible for some relief, but w/o medical marijuana laws to help, I’m suffering! Please stop punishing the people who really need these meds, when tbe actual addicts are still getting their drugs illegally! Absolutely despicable!

  • I was curious how the “war on drugs” is going for law enforcement. After all, there’s a lot of bragging, like beat chest bragging. So I looked online at the dockets for arraignments in court. I saw a lot of defendents, prob over 100. There were 3 cases of possession w intent distribute out of the whole docket(s). Most of the cases were failure to pay child support. I guess they never considered that their big busts and progression can be fact-checked.

  • Its all just demonizing the American citizen who wants to live a better quality of life.we don’t want to live with crippling pain that controls every part of our lives and its considered the oath of physicans to treat in all ways possible the conditions of their patients.But big brother has a short leash on perscibeing physician’s or should I say gate keepers well what are all of the pain management Dr.s gonna do when they can’t have anymore patients guess they will have to become the dudes on the street corner just to make a living what a joke you dumb asses guess what you forced granny to smoke weed get addicted to herion because some stupid ass decided he would overdose based on unproven study’s take care of yourself the best way you can folks because we are all deploreables and now orphans that can’t get help to help with our pain

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