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.

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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.”

  • I read what the cdc is saying in trying to clarify this crap they put out causing much pain and misery to literally 10,000’s of patients. The ‘authorities’ have become overzealous in their enforcement which naturally scares the bejebbers out of the Doctors who can’t afford to loose their license or face censor. When you have patients on long term opioid therapy who are unreasonably either rapidly cut back on dose or cut off all together you have ruined lives, caused suicides, and patients who have been abandoned or cut back severely to seek other means of control or just have to live with their lives messed up by the chronic pain they suffer. Shame on the CDC and the authorities. When you have pain management specialist scared to do what they are trained to do and know what is right freaking out then you need to wake up CDC and truly clarify your mistakes or admit you did intend to cut opioid prescriptions no matter the cost to those who have just them responsibly for years. I am ashamed to admit I am in the medical fraternity at this juncture in my life. I can remember my dad, an MD family practioner, the old guys who did it all, OB, surgery, general medicine, fix broken bones, sew you up, did house calls, etc. being paranoid about giving opioids back in the late 60’s and early 70’s so what changed? We know what changed and partially some drs. are to blame as well as pharmaceutical companies. However you don’t throw the baby out with the bath water. I too am a long term responsible opioid user, always from my pain specialist. These greatly improved my quality of life. Now with the cut backs not so much. All the theory about using other means to control your pain sound good. However I can state as one opinion that I don’t have time for all of that. I am 68 and still work 60 hours a week. Now that the medicine has been cut back, and I might say too fast, say 30 medd in one month one time and when I was at 135 medd 45 mg. in 1 month. That is how dang scared the pain specialist was. My last visit I complained about it and the rapid taper, etc. He basically said it wasn’t his idea for the state medical department to come down on him, as well as other authorities, causing him great anxiety. As a pain specialist he would be expected to write a lot of meds. However it seems the way they are screening doesn’t take into account that is his specialty. Pain meds should be prescribed by pain docs for long term, greater than 1 month for sure and primary care should not be doing that, as a general rule. Again, so disappointed in all the authorities on this. Back the heck off and let us legacy patients go in peace. Just Google pain med cut backs,etc. and see all the poor souls whose lives were irrepairably harmed. How about their rights. Oh, and not to mention all the insurers now will not cover the doses that are needed, again, cdc. Damn the cdc and all the cohorts here. The docs don’t tell the patients to take all the pills at once and get a snorkle and dive to the bottom of a liter of jack or crown, did they? Oh, and then go for a drive in their cars and kill themselves and/or others. CDC be damned.

  • My life has been miserable since being made to change my medication and reducing my medication for chronic pain. I was doing very well with my (oxycontin) medication that I had been taking for years, my life was back. Now, I cannot even clean my yard, go out, it is a real chore to do anything and very painful. Why can’t the CDC put out in simple words that patients like myself who have been on meds that really made life doable for years is ok. Doctors and Pharmacists are scared, THIS HAS TO STOP, I CANNOT TAKE IT MUCH LONGER.

  • After being abandoned by his Dr. on January 2020 with no notification
    A new Dr that took over practice forcing rapid taper –
    Assessment:
    Your notes indicate you are not comfortable prescribing current medications that ———- prescribed as currently as of 12 – 2019 to a stable patient.

    You have caused ____ to be unstable with life threatening blood pressure, anxiety raised, pain, completely running out of medication on 2-15-20 as per our conversation on 2-12-20 on a unjustified rapid taper which is unjust per cdc guidelines , new England journal may 2019 publication, taper/reduction does NOT apply to a stable patient that has been taking prescribed medications for approx. 20 years.

    Pain pump was suggested for __________which is incorrect for ___because of crps
    He doesn’t have dental work performed because of increased pain due to crps let alone any type of surgery that can make crps worse. Also he is allergic to demoral, morphine so a pain pump is NOT the answer.

    Belbuca coincidentally came out in 2016 same time as the 1st cdc guideline and after reading over 100 reviews all negative so this is NOT the answer.

    Noone I have spoken to can fathom why you are doing this rapid tapering to a once stable patient.

    After 20 years you are questioning his crps by a bone scan that can or can not show crps ?
    We fought for years confirming his crps when we didn’t know anything about this horrible illness.

    A dr. is supposed to be compassionate and caring and to do the right thing for a patient.

    You have disrupted my life, my daughters, and most importantly ______

    Approx 20 years ___has complied with everything that was asked of him except for Jan 2020, Feb 2020 when you have abandoned him causing undue stress and anxiety on a once stable patient that you have made UNSTABLE.

    This is a horrible nightmare that has caused stress, anxiety for not only ____but, for our family and friends.

    You have put ____in a cookie cutter treatment plan instead of an individualized plan for pain.

    HHS guide 10-2019 risks of rapid opiod taper
    1. Opiods should NOT be tapered rapidly or discontinued suddenly due to risks of significant withdraw
    2. Risks of rapid tapering or sudden discontinuation of opiods in physically dependant patients include acute withdrawel symptoms, exaberation of pain, serious psychological distress, thoughts of suicide, patients may seek other sources of opiods including illicit opoids as way to treat pain & withdrawel.
    3. Unless there are indications of a life threatening issues such as warning signs of impending overdose , HHS does not recommend abrupt opiod reduction or discontinuation.

    This is barbaric on what has happened to us this month .

  • I’m very sorry for what you have to go through Gail.
    As for the CDC, they intentionally deceived each and everyone of us! They chose to ignore protocol for receiving information that was definitely based on specific doctors prejudice. This bias information was used to discredit the use of opioids and to promote their own selfish agendas. Here is a site that Steve has put up so we can farther or education in how corrupt the CDC has become.
    Washington Legal Foundation letter to CDC about opiate dosing guidelines concerns
    Posted on February 2, 2019 by Pharmaciststeve
    http://www.pharmaciststeve.com/?p=28656

  • This is a very contradictory article. CDC didn’t mean it as hard and fast law with the first set of guidelines NOT LAWS. THEY KNEW THE STATES WOULD AS THEY SAW $$ SIGNS from PHARMA. But that is what all 50 states did…Follow the Money, states wanted Billions from Pharma and move to big chain Pharmacy. Then you have the Coward doctors who Abandoned their patients who had 2 choices left Suicide or DOPE. 3 yrs ago all Opioid based products became that, No differing between Street DOPE bought in seedy places vs Prescription Pain Meds filled by a Pharmacist with instructions how to take. World of difference, 1 needs a prescription, Ins. Pharmacy to fill. The other is just bought in a seedy bar or alley cash only. I am 71 nearly 72, I lived through the age of hippies and DOPE of all types. MMJ was a favorite, LSD and Magic Mushrooms. Which are now being recommended for Pain. All they do is get you High and Spaced out so you forget for a while how much pain you are in. Spinal Cord simulators bring their own set of problems, Adhesion can form on the probe they stuck in your spine. Batteries need another surgery to be changed, some models are out right dangerous, Adhesion can form from the numerous surgeries. We have total Idiots running the CDC, DEA and dare call themselves coward doctors. FOOLS doing damage and harm. Treating Patients like Criminals, raiding Pain Clinics with AK 47’s as if they were taking down a Mexican Drug Cartel; instead of terrorizing sick and elderly people in a Pain Clinic.

    No mention of the Bias by the CDC Director as his son 37 is a Street Junkie/Addict who depending on the news paper you read OD’d but lived on Heroin/Fenatayl or Cocaine/Fenatayl. Declared WAR on OPIOIDS. All he declared WAR ON WAS PRESCRIPTION PAIN MEDS. Easy targets as they leave a paper trail. Where as DOPE ADDICTS, STREET JUNKIES PAY CASH.

    What a big set of LIES and MSM, Congress, Doctors just let them get away with it for those $$. I recommend every doctor who Abandoned patients be Strip of DEA licenses forever. 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.

    Wrongly IMPLEMENTED IS THE BIG LIE. They knew INTRACTABLE PAIN PATIENTS would have heart attacks and die, strokes, commit suicide or turn to risky street DOPE.

    Lets not forget the BIG FEES PROP addiction SHRINK ANDREW KOLONDY would get for testifying around $500,000. Then there was travel, hotel stays at $425 a night, meals and booze. Tax payers paid for. NO person at this level needs this kind of Stipend for travel. They are after all not even Senate Vetted and approved. They are Party leadership approved, who were recommended by former Governors or congress critters since they are sensitive if you get their questionable gender wrong; in this case a Bitter loser for President, Chris Christi who just happened to turn up with a $800,000 book deal out of it. A new President with thousands of people to appoint to positions took those recommended as honest, not realizing they HATED HIM as he was Not a Politician, conveniently forgetting he contributed to their election campaigns, had you over to his home; boo-hoo you lost because you voted the opposite of what you campaigned on. Hee dared to promise to clean out the greedy Swamp YOU! who were getting rich by sitting on a Big business boards with no reason other than Your name on the board looked good, and paycheck for doing so making you very Rich. Who was shown addicted born babies and crying parents of dead OD’d college Adults. Or the person who OD’d and wanted revenge. A man who watched his own brother die of Alcohol Addiction.

    No one mentioned INTRACTABLE PAIN PATIENTS and what would happen to them.
    This new set of guidelines comes to late for many of us, and is WORSE than the Original.

    Idiots who call themselves doctors recommended prolonged use of OTC pain meds forget they damage and kill. All but Tylenol is a blood thinner. Thus useless Post OP. Epidurals for child birth were recommend using the GI destruction, blood thinning drug Toradol in your spine. Wonder what it did to spines? Mobic is another GI destruction drug and a Blood thinner. Bet no one tracked it, no more than they did the heart attacks, strokes, or Suicides they could blame on existing conditions or PTSD. LEAVE MANY LETTERS WITH RELATIVES IF YOU DECIDE THIS FINAL ROUTE. Make it known CDC AND PROP DROVE YOU TO IT. Your congress critter at either state or federal level are NOT going to tell the TRUTH. They have their fingers in the PIE. And you are NOT getting your dignity nor PAIN MEDS BACK! Kill you off so more Illegals can have Free health care. You can’t take politics out of Medicine they make the laws, and their agency’s approve the drugs. Which for the past decade have been harmful, cause other diseases, horrid side effects or Cancer you die of.

    I’m angry, I am one of those Intractable Pain Patient who can’t take OTC or Prescription Pain Meds due to a Osteoarthritis drug ruined GI tract. I have Barrett’s Esophagus 2 spots, a hernia from all the Puking because Diagnosis was wrong. Didn’t you learn in Med school the difference in Gastropresis and Idiopathic Colitis? Now welcome to the Type 2 Diabetes I now have along with a ruined non fixable spine. Where is MY pain relive? Colon is shutting down, AB is swollen like a 9 month pregnant woman. Rember I’m soon to be 72. The diets are Opposites and there is NO middle ground.

  • Tamara…..I feel for you and have faced similiar issues after being treated for 27 years. I lost my pcp, went to a pain specialist who tapered my meds significantly more than recommended. Everyone is in the same boat. The only option is to write to your local congressman and other political entities who are in jeopardy of being voted out over all of the issues caused by synthetic opioids and illicit transactions. Good luck!!

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