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.

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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  • the reason the devil and all his minions are picking on all of us responsible patients with severe chronic pain is because its easier for them, then to be going after the real evil people in this world.In the mean time we will all suffer.Look how much there helping innocent children who keep being killed at their schools.In the last year there has been at least three mass shootings in the U.S .Neither one of these things should be happening in this day and age.This world we now live in is so corrupted,we should have the legal right as citizens to fire all these …………..,And have people in office who actually give a damn.It makes me sick to think about it.,

  • I don’t no how anybody could no what pain patients are in and what pain they deal with on a daily 2004 I worked for a stone plant and we just got done putting a new set of rollers and brand new rubber belt on a 40 foot stacker we turned it on to make sure it was running true but it started to smoke at top of stacker pulley so belt was turned off my supervisor told me to go up the belt and see what was going on so I did found a rock stuck in tail pulley kicked it loose then started down the belt man in control house turned belt on by accident threw me 40 foot down ward on to main crusher belt that was on and hit my head on tail pulley motor had all my perfectly good teeth knocked out and broke my jaw 3 places no movement waist down head was swollen air faced to hospital at witch time they had to do something about swelling of my head and see what the lack of movement from my waist down had very severe head injury and several back surgeries witch resulted in a metal bone cage between myL-4 and L-5 never to be able to return to work and head injury caused memory loss for rest of my live and severe pain on daily bases I was taking oxycodone from 2004 to 2015 until my doctor had past away and I went for almost a year before I could find another pain management doctor.but I did been with him almost 2 years now their talking about limiting oxycodone to people who live in daily pain they had to induce coma due to swelling in my head for safety reasons. I live in pain daily and now threatening to take my pain medicine away not fair to people that need it but yet they don’t care about patients that are even lucky to be alive

  • My family doctor in a rural community gave me a urine test. I My pain doctor in the city layed out a plan for care in between pump refills. My rural doctor decided to let me go into withdrawal with no warning because I took my last Xanax and took the valium he decided he wanted me to take. Shouldn’t he have tapered me off instead?

  • Junkies will find a fix no matter their weapon of choice. Like millions of pain patients, I lead a productive life, follow doctors orders, and have attempted every single non-medicinal solution available. I haven’t slept more than 4.5 hours in years but still work 60 hours per week. I can only hope someone will realize by universally terminating or greatly reducing access to opioids the wrong citizens are penalized while the junkies will continue to abuse the latest craze. There are ways of managing opioids while not destroying the lives of those who truly require pain medications. Praying common sense will prevail…………

  • Does the patient have anyone that they can contact to be an advocate for their rights on this wrong?
    Making it impossible financially for long term responsible patients to continue their medication, no matter how “noble” the intent is claimed, is not ethical at all.
    So, if one can afford to pay a Dr. & pharmacy every 7 days, they’re allowed?
    The article nailed it. These people are going to ruin many more lives via driving them to the dangerous black market, withdrawals, depression/suicide.
    There has got to be an entity to protect the responsible patients?!

  • All our lives we’ve done exactly what the doctors have told us, being the perfect patients and for what to have our self-esteem beat down as if we are junkies out on the street begging for money to get our next fix. I am tried of all the excuses and run around I get which consumes all the energy I have. I was diagnosed with GPA , contracted hepatitis B from all the blood and platelet transfusions I received over the years and the 19 surgeries I’ve lived through. I was just diagnosed with lymphoma and today I went to see the fourth pain management doctor five referrals stating that they wanted me to be put on a pain program called palliative care in all Capital letters my doctors stated please do not make any changes to this referral this came from four different doctor doctors such as a pulmonary specialist a rheumatologist a cardiologist and primary doctor, but do you think that any of these orders have been followed absolutely not. I’ve been sent to detox clinics “ doctors “ that seem to know more about my disease than the doctors who are learning about how and what the disease is it’s a type of autoimmune disease that acts whatever it pleases for myself it’s been completely facial reconstruction, lung disease, heart disease, going blind in left eye and now I was informed that I have lymphoma. But today I was told by yet a supposedly a pain management doctor that she was taking me off all the medication I have been on for over 14 years with the same pain management doctor. Does she have a bag of tricks that the rest of her colleagues have absolutely no knowledge about, . There’s got to be something done. I say it stops here, if just a handful of people get together via text, email, phone or FaceTime and come up with a plan than we present it to the rest of the suffering patients maybe just maybe we will get the help from people in power to take notice and help us find a way for change. I would be willing to a person who does the research trying to get ideas for how to start find ideas for change. If anyone is interested in finding ways to make a change please contact me anytime day or night

    • I am definitely interested in joining in the fight for change. My husband has bee referred to (by several doctors) as the “POSTER CHILD FOR PAIN MANAGEMENT PATIENT” . He is 67 years old and as the result of POLIO as a child, numerous surgeries taking bones from one leg & putting them in the other, etc.. he was never supposed to be able to even walk but against all odds he did walk & managed to work full time & overtime jobs including working in the coal mines in WV, working for waste treatment facility, working for FEMA, Maintenance Supervisor at a nursing home, Commercial & Residential Electrician, etc… he finally became unable to continue working as his health began to decline, and at best he could walk only with the use of a walker or cane, and even then still took 8-12 falls a day. He suffers from POST POLIO SYNDROME, scoliosis, degenerative disc disease, diabetes, & the list goes on. He refused to accept scripts for pain meds for years & finally the doctor said either take the pain meds or we will be forced to dismiss you. He accepted them & MY what a difference it made! He was able to live a halfway happy pain free life for the first time EVER! Over the years he finally was up to six 40mg Opana per day, and Six 20mg Oxycodone per day for break through pain. This was working well for him… then with no warning they cut both in half!! Down to Three of each per day & his life took a major nose dive like a snow ball headed for HELL! On this lower dosage he spends about 24-28 days a month laying in bed. His quality of life is ZERO, and his pain is constant! He does everything by the rules! Takes all meds by mouth, never failed a drug screen, never failed a pill count, never violated any rules or policies, yet he is being punished for what others have done & are still doing. I am FURIOUS! It’s just NOT RIGHT!

  • A visit with a new dr. thinks in the name of science they are saving our lives,a word he seemed to enjoy repeating many times over.What they wont understand is our pain medicines have saved our lives. They had given us some quality of life.All their statistics and science is bullshit.What will there reports say in 10yrs.Most likely something alot worse than what they think is shamed now.In the mean time real people with severe chronic pain conditions will keep on suffering.I am very sorry.

  • My wife has been posting her opinion And filed a complaint against her civil rights discrimination and now she has been flagged and can’t get on the sites to voice her opinion

    • I am the one that has been flagged,because I filed a civil rights discrimination complaint against me DEA for Violations of my right to the best to have the best medical care possible and now the DEA is taking the role of physicians, judge and GOD . And all the letters I’ve written to all elected officials and media. I have received notifications from google yahoo and the rest stating I have broken my agreement with their oath

  • I agree with all that was said how the pengalen has swung to the extreme. Junkies are still dying and now you have non street people taking drastic measures to get some relief. Just the thought of spending the rest of your life with a bad toothache! Of course in real world you would just have it fixed or pulled Unfortunstely pain patients have unfixable ailments Like severe oa where almost every joints hurts like hell My case is that along with several disc herniantions. I have had too many surgeries to mention But 2 top notch spine surgeons said they would feel uncomfortable to perform surgery due to too many abnormalities could be causing pain So over a year now I no longer get oxycodone.I gave up going to doctors Always feeling humiliated like I a mad pill popper I will be 63 soon hopefully I will just die of natural causes. Just another casualty of the good decent people and yes regardless what the govt decides the street nudnik will continue to overdose either way Let’s blow up the whole house to kill 1 mouse!Brilliant

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