The authors of influential federal guidelines for opioid prescriptions for chronic pain said Wednesday that doctors and others in the health care system had wrongly implemented their recommendations and cut off patients who should have received pain medication.

“Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations,” the researchers wrote in a paper published in the New England Journal of Medicine.

They said some health care players had used the guidelines to justify an “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages,” when the guidelines did not actually endorse those policies. The authors did not identify stakeholders other than clinicians who they said have misapplied their guidance, but advocates have also accused insurance companies and state agencies of using the guidelines to inappropriately withhold treatment from some patients.

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The new paper comes three years after the Centers for Disease Control and Prevention published the prescribing guidelines, which were meant for primary care physicians treating chronic pain in adults. It follows growing appeals from patient advocates, pain doctors, and some addiction experts for the CDC to clarify that its guidelines were just recommendations. Advocates have argued that strict limits on prescriptions were leaving patients who had been on stable dosages for years unable to stay on their regimens and sometimes pushed them to illicit opioids or even suicide.

The authors of the 2016 guidelines — Dr. Deborah Dowell and Tamara Haegerich of the CDC, and Dr. Roger Chou of Oregon Health and Science University — said in their new essay the recommendations were not meant to be used to withhold drugs from people who need them, and outlined instances of their misapplication.

One example: The guidelines say that “clinicians should … avoid increasing dosage” to 90 or more morphine milligram equivalents per day or to “carefully justify” such a decision. That did not mean prescribers should automatically cut dosages that were already above that threshold, the authors say, “yet it has been used to justify stopping opioid prescriptions or coverage.”

“We know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them,” they wrote.

Still, the researchers say patients who are able to safely decrease their doses face lower risks of overdose, and some experts believe that long-term opioid use actually increases pain sensitivity.

The 2016 guidelines were meant for patients suffering from chronic pain not tied to cancer, palliative care, or end-of-life care. But in the new paper, the authors said that there were reports of them wrongly affecting care for other patients, including those with cancer or during acute sickle cell crises.

The authors also emphasize that the guidelines should not be applied to the doses of medications that are used to treat opioid addiction.

In parts, the new essay reads as a defense of the guidelines, which are voluntary but have faced heavy scrutiny in the years since they were published. The authors note that their original paper features suggestions for treating patients on high-dose opioids, including how to taper prescriptions safely while minimizing withdrawal symptoms. “Though some situations, such as the aftermath of an overdose, may necessitate rapid tapers, the guideline does not support stopping opioid use abruptly,” they write. They also argue that actions by some clinicians, such as halting opioid prescriptions or no longer seeing chronic pain patients, “could represent patient abandonment.”

The federal guidelines were an effort by the CDC to implement safer prescribing practices among primary care physicians, who write the vast majority of painkiller prescriptions. They seem to have accelerated the decline in outpatient opioid prescribing that began in 2012, experts say.

An analysis published last fall found that in January 2012, nearly 6,600 opioid prescriptions were dispensed per 100,000 people, but that fell to 4,240 by December 2017. From March 2016 until December 2017, an estimated 14.2 million fewer prescriptions were filled than if previous trends continued. There were nearly 1.3 million fewer high-dose prescriptions written, as well.

The new essay is not the only step taken by the CDC to clarify its guidelines.

After physician groups argued that insurers seized on the guidelines to deny treatment for some patients, the agency in February wrote to the American Society of Clinical Oncology, the American Society of Hematology, and the National Comprehensive Cancer Network to acknowledge that clinicians and insurers should also consider the clinical practice guidelines each group has issued. The CDC reply was released publicly on April 9.

The Food and Drug Administration announced this month it is providing clinicians more information about how to safely decrease doses for patients who are dependent on opioid medications.

The CDC also recently responded to an ad hoc group of physicians, who call themselves HP3: Health Professionals for Patients in Pain, who have urged the agency to clarify the “misapplication” of its guidelines. The group organized a letter signed by more than 300 doctors who complained the guidelines harm patients with severe pain who may have been taking high doses of opioids for years without becoming addicted.

In an April 10 reply, CDC Director Dr. Robert Redfield wrote that the agency was “working diligently to evaluate the impact” of the guidelines and “clarify its recommendations to help reduce unintended harms.”

One former member of the CDC panel that established the guidelines, Dr. Lewis Nelson, who chairs the Department of Emergency Medicine at Rutgers New Jersey Medical School, says the new essay is “basically, the FAQ that goes along with the policy statement.”

“It’s very clear that when the guidelines were being assembled, a lot of attention was paid to the fact that people shouldn’t be rapidly tapered off opioids, because it leads to a terrible withdrawal syndrome and complicates their lives,” he said. “But it wasn’t just doctors who misinterpreted the guidelines. It was also regulators and legislators. Unfortunately, some must have just read the bullet points.”

A few of the HP3 organizers have relationships to industry. Among them is Dr. Daniel Alford, a professor of medicine at Boston University, which runs a continuing medical education program called Scope of Pain that receives backing from opioid makers. Another is Dr. Richard Dart, who directs the Rocky Mountain Poison and Drug Center and also heads the RADARS System, which tracks prescription drug abuse and is supported, in part, by subscriptions from pharmaceutical companies, including opioid makers.

Such ties prompted concern from Dr. Andrew Kolodny, who heads the Opioid Policy Research Collaborative at Brandeis University and is executive director of Physicians for Responsible Opioid Prescribing, an education and advocacy group.

“I think the CDC is simply reiterating what is in the guidelines,” he said. “But the only thing that troubles me is they might be accepting these reports of misapplication of the guidelines as accurate, when I believe they’ve been exaggerated. There’s been an effort to ‘controversialize’ the guidelines.”

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  • I’m sorry to hear that Mrs Kelly. Like I’ve recommended to other Patients on this board;

    Take a copy of your current medical records and treatment to the State Medical Board and make a formal complaint for unethical treatment for uncontrolled pain.

  • My name is Kelli, I am from Cincinnati, Ohio. I am 51 years old and am horribly disfigured and basically bed ridden due to spinal disease and 2 failed spinal fusions. My life consists of a adjustable bed and a window. I’m unable to get out and participate in life or enjoy any activities with my family and grandchildren due to excruciating pain that the majority of people could not possibly grasp. But in my window, outside , I have a wonderful variety of bird feeders and just yesterday my husband brought home 2 beautiful hanging baskets of flowers ! This makes me happy and I smile. I also have plenty of sprite, coffee, potato chips, dill pickles, Esther price candy, French fries , beef jerky, grape cigars and CABLE TV on a nice flat screen. I know you may be saying….. ok, where’s this going, ? Well, life is what you make of it and I choose life. But now I’m questioning and maybe I don’t have the mental fortitude anymore because I went to my Dr. Today and I was told that they were ” tapering ” my medication for a month. I was confused, angry, sad and afraid. I’ve taken my pain treatment very seriously and have been an exemplary patient. I’ve stayed away from oxycontin , knowing that I will NEVER be pain free for the rest of my life. But at least the 4 Percocet and 25 mcg fentanyl patch keeps me at a steady 10 on the pain scale when resting. Along with lidocain patches , diclulfenic gel , specialized gel cushions, pillows and ice pacts. Why are they doing this ? There are people that truly need and have to have medication. We don’t have a choice! I know if I had a CHOICE I would choose NOT to have a life chained to pain management. Now it’s dirty and EVERYBODY in it is DIRTY! Now doctors won’t or can’t help, then we are looked at as seekers because we are asking for help, but you can’t ask too loudly because you don’t want to run the risk of upsetting the doctor that has cut your meds and now holds your future in their discression. The future terrifies me and if the future for people like us is ” tapering ” then assisted suicide in Michigan or Colorado may be my ONLY choice.? But I want to live………………

    • Kelli, seems like something is bad wrong with your doctor.
      I believe many folks may wish to speak with this person.
      Can you tell us their name? We may be able to make an impression, or an offer, you know, of new information for them to think about. It’s time.
      Hold off on your fears for now.

  • Yesterday at my appointment I brought printouts of several of these articles, with pertinent parts highlighted. As many of y’all can guess, it did absolutely no good. They aren’t going to go back. She won’t raise it 1 mg, let alone the 10 mg (1/2 of what they cut it) that I asked for.
    Uncaring. Abusive. But always pushing those worthless injections.

    • In my opinion we need to sue the CDC and any doctor who tapered or stopped pain meds for what they did. I have information shows the CDC knew the 2016 guidelines were misleading, misapplied and doctors were using them without reading the full guidelines. If they had section 5 has a few paragraphs about established, grandfather or legacy patients and state tapering meds was voluntary and between doctors and their patients. I’ve kept track of articles and letters sent to the CDC about the misuse of the guidelines back to early 2017. In 2018 the CDC admits the number of overdose deaths related to prescription pain medication were inflated by 53% and more. The numbers reported by the CDC of the number of overdose deaths for 2016 and 2017 were wrong. Out of the 63,632 overdose 49,000 were from any opioid. After a year of reviewing the death certificates the number was 17,087 not counting the number of suicides. Same in 2017 numbers, the number of overdose deaths related to prescription pain medication remains the same.
      The CDC knew it when the guidelines were written and now they are doing nothing to help CPP getting their lives back. I am looking for an attorney to sue for discrimination against a disability, the FDA for ignoring the new findings and the doctor that stopped my meds and any other thing I can think of. I encourage anyone who can join with your state and hopefully we can make it a class action suit.
      IMO…..

    • Julie, You can take a copy of your treatment records and file a complaint against your Doctor with the State Medical Board for Insufficient Treatment of your pain.

  • So this is great but states like ca and hmos like kaiser says 80-90 mgmme is what the LAW is.
    I have yet to find the law, anywhere. THE CDC MUST DICTATE TO THESE HMOS LIKE KAISER THE CAN NOT OVER RULE THE CDC OR FDA. THE REALiTY IS THEY DONT CARE ABOUT THE PATIENTS, THEY CARE ABOUT MONEY AND THE BONUSES THEYLL GET BY DECREASING PRESCRIPTION COSTS. I HAD AN HOUR MEETING WITH MY DR TODAY AND ALL SHE SAID WAS KAISER AND CA SAYS 80MGMME IS THE LIMIT. I STRESSED MAYBE FOR NEW PTS BUT IVE BEEN ON A HIGH DOSE FOR A DECADE AND THE CDC AND FDA CLEARLY STATE THAT THE LIMITS SHOULD BE USED FOR NEW PTS NOT LEGACY THAT WERE IDEAL PTS THAT FOLLOWED THE RULES AND BENIFITED FROM THE MEDICATION. NOW I AM COMPLETELY MISERABLE IN CRIPPLING PAIN. NO COMPASSION AND NO CHANCE OF GETTING MY DR TO RAISE THE DOSE NOW THAT SHES CUT ME BY OVER 50%. WHAT CAN I DO??? PLEASE ADVISE.
    SHOEHAUSE@GMAIL.COM

    • Did you show your doctor the new guideline information the CDC released in April? It shows the dangers of tapering or stopping pain meds for CPP?

    • Hi Scott,

      Please post the California Law that you are referring to that says a Doctor has a limit of 90 mg of pain medication. There is a lot of misinformation being broadcast by the media.

  • I want to know what now?

    I was with my pain doctor for 20 years and on the same dosage when on 4-23-17 the medication that controlled my pain were stopped. I arrived for routine follow-up when a new doctor walked in to tell me he is stopping all pain medication within one month by forced taper. It took me six months to find clinic to accept me as a patient and he treated me like a new patient.

    My worst pain is 4 different migraines including chronic cluster migraines, several ruptured disks from a back injury and severe disk degeneration. Spinal Bifida, Scoliosis, fibromyalgia, chronic kidney stones and more.

    8-23-2018 I had one of the worst cluster migraines on it’s 5th day, disk rupture pain was hurting and my chronic kidney stones started dropping. this was my 4th episode this year. I was in horrific pain.

    I have a pain contract so my son called the clinic to let them know he was taking me to the ER. He was told he could take me but under no circumstances could they give me any pain medication. My son called 3 more times; on the 3rd call was told we needed permission from the doctor and he already left for the day. No one told him about me.

    No one should suffer horrific pain. Our doctors abandon us and a pharmacist profile us and refuse to fill our prescriptions. A family pet would never be allowed to live in pain. The family would show mercy and let the pet go to sleep.

    Before April 2017 I was happy, involved in many craft projects and saw my daughter and grandchildren often. Because of the migraines my husband created a dark room and I spend most of my time in there.

    Part 2
    This doctor was fired for this and what he did to others. The Doctor who took over is an anesthesiologist and they are the best doctors to treat pain. He started to give me back my original pain meds. Up to almost 1/2 now. Why did it take 4 years for the CDC to admit they f*up. What now? Will we be told “you’ve been surviving all this time with 90mme why would I raise it?

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