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 am a 69 year old woman with 4 debilitating conditions that give me horrendous pain and fatigue. For 11 years I have been taking the lowest strength hydrocodone prescribed by my rheumatologist, who is a fine person and even better physician. I would be unable to participate in my own life without taking this medication. Even with this med there can still be days where I can’t get out of bed or just sit slumped in a chair. I was told last week that the number of pills I currently take, which is 5, will be dropped to 4 for a couple months, then to 2 and then none. I am so preoccupied with what I know is coming that I can hardly function. My caregiver, my loving husband, is none too happy either. I was also told that this will happen to all patients, including those with cancer. I am just a little granny who wants to be with her grandchildren, go to church and otherwise fully enjoy my life. Doesn’t look like that will be possible in a few months. Disgusting and shameful.

    • Diane;
      I’m so sorry…I understand what you’re talking about. Tho I don’t have kids or grandkids, but I do have a dog I love very much & hope to be around long enough to give a good life to, & at times I wonder if I’ll be able to. I was on a dose much lower than the stupid 90mme for many years, & got force tapered also. I don’t know what state you’re in, but the leading state for anti-opioid extremists (Oregon) just decided not to force taper all its medicaid patients to zero, after nearly 2 years of heavy fighting by advocates. Maybe –maybe– between this glimmer of sanity & the CDC & FDA finally coming out, things will turn around. I dearly pray it’s soon; for your sake, & mine, & millions of others who’ve had their lives destroyed for NO REASON. I can’t bear to think of the people who’ve taken their lives due to intolerable, untreated pain during the last 3-4 years, or their loved ones. Wishing you the best.

  • I am a Retired Federal Narcotics Investigator with over 20yrs Service, (10ys Overseas). I had worked all levels of narcotics enforcement ranging from; Street Sales, to International Narcotics Smuggling, Prescription Medication Counterfeiting and Smuggling, andcDomestic Drug Diversion, (Diversion cases made up less than 1 % of my drug prosecutions).

    I suffered a severe on-duty traumatic injury to my C-Spine which subsequently resulted in an unsuccessful 80% Cervical Revision. For over a year Post-Op I fought hard through Physical Therapy attempting to return to full duty, but I could not stop the Tension Headaches, Cervical Pain and Muscle Spasms and was forced to retired from a Career I LOVED. I lost a significant amount of Pay and Retirement earnings as the Federal Civilian Disability System only pays you at 40% of your salary for FULL DISABILITY. Fed. Law Enforcement NEED a system similar like the VA, where you get a rating and are paid for your disability rating.

    I have tried the plethora of NSAIDS, SSRI’s for Pain, Nerve Pain Meds, (like gabapentin etc) that did nothing for my pain. The most effective pain medication that I have found is Oxycodone with a small Benzodiazepine.

    Unfortunately, in 2016, after being on this regimate for over 6 years without any adverse affects, Doctors eliminated the benzodiazepine FOR THE SOLE REASON; THAT THE CDC ISSUED GUIDELINES ABOUT PRESCRIBING OPIOIDS and Benzodiazepine. The Benzodiazepine not only helped the muscle spasms, but helped me sleep.

    Now, in 2018 the Insurance Companies have given notice to my Board Certified Pain Specialist that, pursuant to the 2016 CDC Opioid Guidelines, they will DENY ANY FURTHER INCREASE/CHANGE IN MY PAIN MEDICATION. These unjustified restrictions should be illegal as it’s a medical fact that a Chronic Pain patients have Ebbs and Highs in pain levels and then develops a tolerance to opioids. This tolerance WILL REQUIRE A DOSING INCREASE OF OPIOID MEDICATION.

    These actions by both the CDC and the Insurance Companies amount to CRUEL AND UNUSUAL PUNISHMENT, DENIAL OF PROPER MEDICAL TREATMENT AND A VIOLATION OF MY CIVIL RIGHTS.

    It’s a cruel correlation that I dealt with Illegal Opioid Addicts as a Narcotics Investigator and now my Quality of Life REQUIRES THE MEDICAL USE OF PRESCIPTION OPIOIDS TO FIGHT MY CHRONIC PAIN.

    IMHO, There is NO OPIOID CRISIS! The Smuggling of Addiction to Heroin and Illegal Opioids has existed in the U.S. since before 1950’s YET NO GOVERNMENT ENTITY ATTEMPTS TO STOP THIS ISSUE BY; INSTITUTING DEMAND REDUCTION AND ELIMINATING THE PROFITABILITY OF THESE ILLEGAL DRUGS. Take these two elements away from the Illegal Drug Trade and it will cease to exist.

    Btw, I am now treated as a Felon who is on Parole; I attend mandatory monthly meetings with my Physician, I submit to Urinalysis and cannot travel away from my home location for more than 3 weeks as my pain medication cannot be dispensed for more than a 30 day supply. YET I HAVE COMMITTED NO CRIME OTHER THAN SERVING MY COUNTRY.

    (please excuse any grammatical errors as its late and I’m hurting)

    • Agent 007;
      I’m so sorry for what you’re going through…& what you’re being denied. I know the DEA is getting a helluva lot of badmouthing these days –& some is sure deserved– but individual agents don’t have control over the policies, & someone who served in law enforcement & is then thrown under the bus is just wrong. Any of us getting thrown under the bus is wrong, & there is one humongous crowd under that bus these days.

      Prayers that we ALL can get decent & adequate –and sane– treatment soon.

  • The CDC would like us to believe that they only realized the impact of their opioid guideline release is a blatant lie. They have known from the beginning that their “guidelines” were being treated as law, and that chronic pain patients were suffering and committing suicide from the fallout. The truth is, they looked the other way when reports began to flood their office. The CDC Dr.s had to one of two things. Either they are grossly incompetent, or the just didn’t care. Any physician knows what happens to people who have been on opioids for years and are suddenly cut off of their medications or are forced to suffer severe tapers. For that matter, so does the public. Early on, the CDC had been dishonest about the percent of opioid related overdoses, only fessing up after the “mistake” was pushed in their faces. Now, they want us to believe that they had no idea what was happening.

    In March of ’18, I became a casualty myself. Since 2003, I have been with the same pain care specialist at the same clinic. Following a ten day stay at the local hospital for a migraine that was not responding to non-opioid medications, the neurologist there started me on methadone. Once discharged, I began treatment with a local pain management clinic and my current Dr. Methadone was not started as the first, second or third medication doctors had tried. From adolescence to age forty, one after another Dr. tried migraine preventatives and a laundry list of medications both specific and off label without any success. Not only was the pain increasing in number and severity of my migraines, but they were beginning to rip my life apart. I took my biochem final at a desk the teacher had put just outside the men’s bathroom so the distance I had cover in order to throw up was minimal. Answer a question, puke, question, puke. By 2003, the pain was constant and differed only in the severity during the day. Methadone was a Godsend, and I knew a day without pain for the first time in close to twenty years.

    Over the years, my Dr. added, subtracted and rotated opioid medications, and added a benzodiazepine. Both of us followed the rules, including contracts, three to four face to face appointments a year etc. Apparently, the CDC doesn’t much care whether the rules concerning treatment with a scheduled substance are followed or not. Opioid therapy for over 6 months and suddenly a patient is either an addict or has opioid misuse disorder. I began emailing the CDC and our state Governor. Over the course of a year, I emailed them several times each, giving them graphic details of what my taper was putting me through. The CDC had the gaul to tell me that the guidelines would be reviewed in a year. Receiving a return email was directly dependant on how rude the emails I sent were. They knew, and if they say they didn’t, they are lying. Note the lifting of restrictions will not go into effect until 2020, and only concerns drugs used in treatment of opioid misuse disorder and addiction. Once again, chronic pain patients are bypassed. The lifting of restrictions in addiction treatment are supposedly to reduce trauma and death from withdrawal of opioid medications. By 2020, all of those pesky patients this restriction will help, will be dead by then. The rest will have already rotated out after treatment available now. This is a pattern with the CDC. Make a promise to ease the suffering of patients, but make sure they won’t need the restriction by the time the lift goes into effect. Personally, I think the CDC wants to eradicate all opioid prescriptions with end of life patients an exception. That done, anyone possessing or ingesting opioids will be using them illegally. No extra work routing out guilty Dr.s or patients.

    By the time my Dr. was forced to taper me, I had been on a stable opioid dose for 4 years, round the clock with x number of rescue injections for breakthrough pain. By the time the taper ended, I was left with 1/10th the dose I had been on. My life is now spent in a dark bedroom, trying not to move lest a breakthrough that will be impossible to knock back occur. Currently, I am on a taper off clonidine which is a medication used to ease withdrawal symptoms. Side effects of clonidine withdrawal are much like opioid withdrawal symptoms. Nausea, vomiting, rebound hypertension. All things that scare all migraine sufferers. This is a day to day battle with the life sentence the CDC gave me. Punishment for a crime that neither I nor my Dr. commit.

    • As another long-term migraine sufferer who actually gets considerable help from opioids –or, I got it when I could get them– i hear you! We’re perfect proof that “one size fits all” does NOT fit for ANY condition…especially complex conditions!

  • I was with my pain doctor for 20 years when on April 2017 the medications that controlled my pain were stopped. That day I arrived at my doctors office for a routine follow-up when a doctor I had never seen before walked in. He said he was brought in to take everyone of their pain medication within one month. Because I broke into tears and begged for an extra month he gave me one full prescription and the second month the forced taper.

    My worst pain comes 4 different types chronic migraines including chronic cluster migraines. A lower back injury L-4, L-5, S-1 including a rupture at T-11-T-10, Spinal Bifida scoliosis and my neck is fused. I also have fibromyalgia, chronic kidney stones and sever facet degeneration.

    The 3rd week in August 2018 I had one of the worst cluster migraines I have ever on it’s 5th day. My back was really in pain and my chronic kidney stones started dropping this was my 4th episode this year. I was in horrific pain.

    My contract with a new pain doctor requires me to contact the clinic if there is a problem. My son called the clinic to tell them because of the of unbearable pain I was in he was taking me to the hospital. He was told he could take me but under no circumstances could they give me any pain medication. My son called three more times; on the last call he was told we needed permission from the doctor and he had already gone home. No one told him about me.

    No human being should be forced to live in horrific pain 24/7. Our doctors have abandon us ignored our pleas for help, pharmacist profile us and refuse to fill our prescription, even for cancer. 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. I have not seen her in over a year. Because of the migraines my husband created a dark room and I spend most of my time in there.

    CDC admitted they inflated the number of overdose deaths related to prescription pain medication by 53% 4-2018. The AMA in 12-2018 condemns the CDC MME.

    The CDC after 4 years admit the 2016 guidelines were misleading and misapplied to chronic pain patients. Why did it take them so long when they knew about this in 2016? The CDC is responsible for every suicide and every patient forced into trying street drugs for relief and overdose.

    What I want to know is what are they going to do for the chronic pain patients forced into a taper over 1 month or stopped on a follow up appointment? How are you going to fix this when our doctors are still threatened by the DEA?

    After the doctor was fired for this incident a new doctor took over who is an anesthesiologist. He started to give my medication back and we got close to what I’d been on for 10 years and same dose. Today at my follow up appointment he tells me the DEA is investigating him and he needs to start a taper. He read what the CDC had to say about force tapers but because of DEA there’s nothing he can do. WTF? Do we need to sue the CDC, FDA, DEA and HHS? What else can we do?

    • Hey Chris! I’m sorry to hear about your pain and the continued problems with your chronic pain doctor. I too am experiencing similar issues with the taper. The CDC admitting the guidelines were misapplied, I don’t think is going to be enough. Until the DEA and everyone else on the doctors back are stopped, we’ll continue to suffer. Our doctors are terrified of losing their license and going to prison for doing the job they went to school for. My doctor is tapering everyone because he’s witnessed so many fellow doctors being taken off in handcuffs for doing their job. I’m afraid we still have work to do before doctors feel safe to practice again.

    • Do we need to sue the CDC, FDA, DEA and HHS?

      YES! We do need to. Maybe a class action law suit.

    • Does anyone know of a class action lawsuit already in the works? I guess it’s time for some research on our next step to get our lives back and the decisions on how to treat us back in our doctors hands! Sign me up!

  • Chronic Pain Patients are the Lepors if 2019. We are denied Human Rights, Civil Rights, and HIPPA protection. I am a chronic pain patient and my pain is so severe caused by lumbar arachnoiditis and cervical neuropathy, which shows on my nerve conduction study/EMG. Though doctors admit I’m in a bad way and acknowledge how severe my pain is, then counsel me on suicide among pain patients who can’t get their pain treated, still are only willing to take the edge off…all because of Andrew kolodny and his lies about opioids. I have written all my representatives for California plus a few more but nobody has offered to half pain patients why? As we are sent home to suffer until we kill ourselves or navigate the streets for pain relief that ass Andrew Kolodny continues to spread bs. He and Heller University should be held accountable for all the suicides caused by denial of pain relief. Why don’t you look into it, and contact some of us who suffer constantly. There’s something very wrong about this.
    Thank you,
    Valerie Windsor

    • Yeh, they are all being either willingly ignorant and/or just plain unsympathetic and lacking of any compassion. That dr. kolodny is really out of this world! I hear he is a psychiatrist who should genuinely care for people but he always seems to go out of his way to bring harm to pain patients. Almost like he enjoys it. Really is something wrong with HIM. Other people in authority should have him removed from his position because he should most certainly be the last person to be in a job that he has.

  • I am a trauma RN attacked by a Meth addict and an 18 inch stainless steel cast spreader.
    My surgeries were another disaster. I was left an incomplete quad. My spinal cord in my neck for 2 1/2 inches “looked like a black and blue sponge”. I can walk but when I stand it feels like a bomb has gone off under me!!!!
    I have been fighting my health care provider for the last 2 1/2 years having either my “low dose baclofen” and methadone “tapered. The woman who had been prescribing my methadone overdose me and then calls and says she is taking me off my pain meds. I have lost both of my children and was suicidal a day, although I wanted to be with them every day. I have been talking to my shrink about this and my meds for the same amount of time.
    I “had to agree to take Lamictol to keep my Methadone dose”. THAT MADE ME SO SUICIDAL I WAS BEING SET UP FOR ELECTRIC SHOCK THERAPY.
    I am also the only patient I know of that has to pee the last 3 -4 months for a urine screen, which is discrimination. I made a point of them not following the CDC guidelines ………….

    Bottom line I know off a patient who asked for the “Death Pill” which is legal in California and we can’t get that either so all that is left for us is suicide and I DON’T want to do that. I have a 3 year old Grandson who I want to see grow up for as long as possible.

    I even have a very prevalent tattoo on my left arm that says DNR!
    This is life or death for me.

    • Hi Sonia. I am speechless. Don’t know what else to say except I pray for you and hope all the best for you.

  • The VS has cut my meds by 30 mgs. Taking my life away, as my brain will not a just to new limits. My blood pressure can’t be controlled, pain pain pain. Falling has become normal again. And now I fear stepping outside my door as weather locks up my whole left side. You have taken the little bit of life i had left, and for this insanity to come from women who have a taste of pain at child brith. I know that GOD will judge them. At the start of this 28 day supply, Real Dr. Think 30 60 90 as the three who write for me can’t seem to get it right after all this time.

  • I cannot believe how these new rules have adversely affected MY life. I had to retire early working in an underground utility all my life and could no longer work. After several spinal surgical procedures PAIN CONTROLS MY LIFE. Even retired now, I can’t experience any quality of life without some pain medications that have become a serious problem to obtain, from physicians who refuse to treat me, to pharmacist who make it nearly impossible to purchase even with a prescription in hand. “We don’t have any, sorry”. I can not visit my grandchildren because I have to see my physician ever 30 days. NO TRAVEL ALLOWED!! As usual, the government has gone TOO FAR!! I’m a Vietnam Vet and can’t even be considered for pain therapy by the VA! Suicides are on the rise, think about that, because there are days I am forced to! IM AM NOT AN ADDICT, and I do not abuse the meds I fight so hard to get. But that’s how I am perceived by ALL clinicians and pharmacist. TO FORCE ME TO LIVE THIS WAY at this time in my life when I should be allowed to enjoy life is completely irresponsible and REPREHENSIBLE. I leave my name at the risk of investigation by the authorities but believe the other side needs to be told!

  • ” ties prompted concern from Dr. Andrew Kolodny…” omg, that’s rich. He’s one of the architects of this homicidal campaign & benefits from both addiction treatment centers & was a total suboxone whore…& he’s “concerned” about others’ ties?! This is like Joseph Goebbels being concerned about whether a PR campaign is sufficiently fact-based. Kolodny wouldn’t recognize a non-biased viewpoint if it bit his head off…& I wish one would.

  • I freaking love it. They sit there for 3 years, doing absolutely nothing (including not even glancing at what effect their “guidelines” have had, much less doing the research & follow up they claimed they’d do), & now all of a sudden they’re claiming that “others” have “wrongly implemented” their recommendations. These people wouldn’t claim responsibility for their own selves if they tripped & fell on top of you. Is this the beginning of their CYA campaign for when we FINALLY get enough publicity that they want to make sure they don’t get sued, or what? If they were pathetic, it’d be a huge step UP.

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