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 a disabled veteran and I’m Rider at Sturgis let’s get all 40,000 bikers together and stop at every hospital VA and CDC centers across the United States in any Hospital let our presence be known or anger be known all doctors in all hospitals have their own parking area I will leave some flyers on their car I don’t know what the Hell’s Angels will do

  • I have been reading comments on here for months now and can not believe how bad things have become for legitimate pain patients. We can no longer trust our doctors or our government after being treated worse than drug addicts. I find it extremely upsetting how addicts are still being allowed to be treated with opioids but those of us who are in chronic pain are cut off completely and left to suffer.

    Here in Maine, doctors are forced by the government to answer numerous questions on individual patients by the government to explain why they are treating with opioids. Our doctors are being threatened by medical boards and the government that if they continue to prescribe opioids they will lose their medical licenses. There is no more doctor/patient confidentiality. There is no more trust after being treated the way we have. Heroin is easier to get and cheaper than having to have a barrage of tests, mri’s, x-rays, cat scans and numerous doctors visits in order to legally purchase our pain medications. Many patients here in Maine are giving up and switching to heroin or illegally purchased pain pills because they have no other option to relieve their pain.

    The CDC should step up to fix this problem they created and admit they screwed up.

  • Population control???? Who has more right to live??? The government has been fighting this so called WAR ON DRUGS for years but hello. People are still making the illegal drugs!!!!! People are still bringing the stuff in from other countries. Pain patients and doctors misunderstanding the CDC guidelines. I understand that what i have read is STILL THE SAME WORDS. Pain patients are to suffer in pain and or even die due to the inhumane ways we all are being treated!!!!! The doctors sure did read the correct information as RAIDS were happening. I know as for myself and I’m sure others as well too, We are just trying to live and take care of our kids and families. We also HAVE PROOF AS TO THE REAL MEDICAL DIAGNOSIS TO BACK UP OPIATE USE. People who have committed horrible crimes get WAY better treatment in prison than us pain patients. People who had A CHOICE NOT to do a hard illegal drug.

  • Yes, I am one of those chronic pain patients that had his pain medication (180 MG Morphine Daily) completely taken away from me by several Navy doctors here in Japan. I had been on a high dose of fentanyl for quite some time, and was completely stabilized. But, because of the 2016 CDC Guidelines, my VA doctors tapered me down to 180 MG of Morphine per day. The Navy doctors that chose to read a portion of the guidelines about the 90 MME and not the rest of the poorly written guidelines, found fit to just cut me off completely from any form of pain medicine or treatment for chronic pain. They cut me off after being on high doses of opioids for over 30 years and then sent me home by myself to deal with the horrific consequences of opioid withdrawals. Not once did anyone from this Navy Clinic call me at home to check-up on how I was doing, mentally or physically. I am a retired United States Marine, who gave over 23 years of my life to defend the United States. I am rated at 100% disabled by the Veterans Administration and also on Social Security Disability for several service connected injuries/disabilities to include PTSD with Night Terrors, Major Depressive Disorder, and Degenerative Disc Disease. I wrote many letters and emails to the following people asking for their help or assistance and not one of them ever responded to my cry for help: President of the United States, Secretary of Defense, Chief of Naval Operations, a few Inspector General Hotlines, Congressman of Hawaii, (just to name a few). I was treated worse than we as humans treat animals that are in pain. I contemplated suicide several times while I was experiencing opioid withdrawals, but because I did not have access to a firearm here in Japan, I just suffered silently. Finally, after a few months of experiencing continued opioid withdrawal symptoms here in Japan, I decided to visit my VA doctor in Honolulu, Hawaii for help. My VA doctor placed me back on 90 MME of Morphine ER per day, for three straight months. On the third month of being on 90 MME of Morphine per day, my Navy doctor in Japan asked his Commanding Officer if he and the Navy Clinic here in Japan could now resume my medical care and treatment for chronic pain. I was given the okay by the Navy Commanding Officer and my doctor to once again be placed on pain medicine. The 90 MME of Morphine that I now take daily for chronic pain helps me function somewhat. But it is by no means a high enough dose to really help control my chronic pain like when I used to be prescribed 180 MG of Morphine daily. Because of what the 2016 CDC Guidelines did to me and other chronic pain suffers, we will just have to suffer alone because no one wants to hear our concerns or complaints. I for one, will never, ever, trust another medical doctor who is treating me; that includes the doctors that are entrusted with peoples mental health and who are supposed to care!

    • I’m so sorry to hear another person being tortured by this country. And it is deplorable after you served your country. The Politicians should cater to veterans above all. I believe what my pain management doc says is true: THE WAR AGAINST PAIN PATIENTS WAS DUE TO $$$$ & the USA ( Not a FREE COUNTRY ANYMORE WHEN TAX PAYERS ARE TORTURED FOR A SURGEONS MISTAKE! Now the CDC ADMITS WE ARE BEING KILLED & DOCS KEEP CUTTING! It’s a Habit & TOO MUCH PAPERWORK FOR ALL MED PROFESSIONALS! I did not have HEART FAILURE & STROKES & NEED O2 @ age 59 BEFORE BEING CUT BACK ON OPIODS & a SMALL DOSE of Klonopin. Now I have SEIZURES & THEY WANT TO CUT MY 0.5 MG. TINY DOSE & I SKEEP 4 hours as is, I WILL BE DEAD & My DOCTOR KNOWS IT. IN LESS THAN 5 years, I WAS A HEALTH FOOD NUT & YOGA TEACHER BEFORE MY SURGERY THAT PUT PAIN TO LEVEL 15! UnBearavle & I PRAY EVERY NIGHT FOR GOD TO TAKE ME TO HEAVEN. 5 YEARS AGO, I LOVED LIFE!!!!

  • Government egregiously overstepped their bounds in publishing the 2016 guidelines. As a result chronic pain sufferers, post-op Pts (disch home), cancer Pt’s, etc. have NOT received appropriate (standard of care) Tx for their PAIN. More focus, resources, manpower & $$ needs directed towards the flow of ILLEGAL drugs into 🇺🇸!!! Govt has NO place interfering into the Dr./ Pt. relationship & the prescribed Tx thereof.

    • I agree with Teresa, does government understand pain better than Doctors or patients. Do we tell the government how much pain we’re in. Healthcare is expensive, I think the government wants a piece of the pie. Or they’re that bored and corrupt!!

  • The article still harps on tampering and cancer patients. It still seems like the CDC and governement are putting Chronic Pain Patients on the back burner. After everything that had transpired the last 3 years since the guidelines. More will have to be done to offset this issue. I’m in a health policy class and illegal herion and fentanyl use is up because of this. While perceptions are down. Most of the problematic opioids come from Mexico. The DEA needs to go back to fighting Cartels not pain doctors.

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