A public health document that counsels physicians to not overprescribe opioids would seem to be an unlikely candidate for attack. Yet the Centers for Disease Control and Prevention’s “Guideline for Prescribing Opioids for Chronic Pain,” published in 2016, has attracted constant criticism since its inception. The attacks come from two directions: groups and physicians who receive money from opioid manufacturers and patients with chronic pain.

Until the CDC began drafting the guideline, opioid manufacturers had a firm grip on what the government said about opioids. The Food and Drug Administration parroted industry messaging on chronic pain and rejected mandatory opioid-related training for physicians. Industry lobbyists orchestrated the creation of a 19-member panel at the National Institutes of Health to coordinate pain research. Many of the panelists were heavily beholden to the pharmaceutical industry.

In contrast, the CDC applied strict conflict-of-interest restrictions to the authors of its opioid prescribing guideline. When the impeccably evidence-based draft was released, the pharmaceutical-industry-funded Washington Legal Foundation accused the CDC of failing to follow administrative processes. The Academy of Integrative Pain Management demanded that Congress investigate how the CDC had developed the guideline. A probe by the House Committee on Oversight and Reform, however, found that the CDC had done nothing wrong.

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After receiving a barrage of complaints from the industry-friendly NIH panel, the FDA, and industry-funded advocacy groups that disparaged both the drafting process for the guideline and its content, the CDC delayed release of the guideline and opened a 30-day public comment period.

A 2017 analysis of the 158 organizations that submitted comments found that opposition to the guideline was significantly higher among organizations funded by opioid makers, life sciences companies, and those whose funding was unknown than among organizations not funded by industry. Notably, none of the organizations funded by opioid makers disclosed their funding.

That was exposed in a 2018 Senate report. In response to a request from then-Sen. Claire McCaskill (D-Mo.), the top five opioid manufacturers revealed almost $9 million in funding of pain groups between 2012 and 2017. According to the report, the “direct link between corporate donations and the advancement of opioid-friendly messages” is evidenced in the groups’ comments.

Some industry-friendly messages were not subtle. The American Academy of Pain Management, which received more than $1.2 million from opioid manufacturers over six years, was dismissive of opioid-associated deaths, stating “… to limit access to opioids because a small minority of people who use them develop a substance use disorder and/or suffer fatal respiratory depression, may be exacerbating the suffering of a far greater number of people whose pain goes unrelieved.”

In its comment, the American Cancer Society’s Cancer Action Network, which received $168,500 from opioid manufacturers, accused the CDC of a lack of transparency, weak evidence, and “failure to adhere to proper methodology in developing the guideline.” In fact, the guideline used a systematic approach of the best evidence available.

Maintaining pain patients on high doses of opioids is a consistent demand of both industry-funded organizations and pain patients. The American Academy of Pain Medicine (not to be confused with the American Academy of Pain Management), a recipient of $1.2 million from opioid manufacturers over six years, criticized recommendations of daily dosing limits, citing the proposed upper limit given in the guidelines as “an arbitrary dose.” The American Pain Society, recipient of almost $1 million, stated in its comment that “these thresholds are clearly arbitrary and without scientific basis.” And the American Society for Pain Management Nursing, which received more than $300,000, commented that it was “concerning to set a maximum dose.”

The assault continued after the guideline was published. Bob Twillman, executive director of the American Academy of Pain Management, lamented about “the apparent lack of response by CDC to comments submitted by the Academy and numerous other pain management organizations and advocates.” The American Academy of Pain Medicine’s president, Dr. Daniel Carr, claimed that “the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence.”

Fresh attacks surfaced in 2019. A letter written to the CDC called for “a bold clarification about the 2016 Guideline — what it says and what it does not say.” Penned by Health Professionals for Patients in Pain (HP3), a group created for the purpose of challenging the guideline, the letter avoided direct attacks on the CDC while bemoaning the “misapplication” of the guideline. The letter’s authors claimed, without evidence, that “draconian and often rapid involuntary dose reductions” implemented by physicians, health care systems, and insurers are driving pain patients to the street to obtain opioids and contributing to patient suicides.

A distinction between street drug users and “legitimate” users of opioids is made by both industry and pain patients. Demonizing “abusers” is an industry tactic. As Richard Sackler, the former chairman and president of Purdue Pharma, the maker of OxyContin, put it in documents disclosed in litigation, “we have to hammer on the abusers in every way possible. They are the culprits and the problem. They are reckless criminals.”

While some of those who signed the HP3 letter have close ties to industry, many of the 300 signatories were well-intentioned health care professionals who did not realize the letter echoed marketing messages. They were used by the organization in much the same way opioid manufacturers use pain patients: as cover for industry efforts to maintain chronic pain as a market for opioids. The HP3 letter, which doesn’t oppose any facts in the CDC guideline and also provides no data supporting its claims, was covered by the New York Times, the Washington Post, Rolling Stone, and other media outlets.

Curiously, when PharmedOut, the Georgetown University Medical Center project that we represent, sent the CDC a letter supporting the guideline signed by seven national organizations and 364 health care providers and allies in May 2019, it received no press coverage.

The formation of HP3 came on the heels of the publication of an article by a conflict-laden group convened by the American Academy of Pain Medicine Foundation. Both the AAPM Foundation and most of the members of what it grandly called a “consensus panel” are funded by opioid manufacturers. The article refutes nothing in the CDC guideline but instead complains about its “misapplication” and — once again — dosing limits: “Daily dosage ceilings, if implemented as hard limits, may promote abrupt dose reductions in patients on high doses, which risks withdrawal symptoms, hyperalgesia [increased sensitivity to pain], and self-medication with more hazardous alternatives.”

Three cancer organizations, the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Society of Hematology, protested that although cancer-related pain was specifically excluded from the guideline, some cancer survivors were being denied opioids even though their chronic pain was related to cancer or cancer treatment.

All of these critics misrepresent the guideline, which never calls for dosage limits, dosage ceilings, forced tapers, fast tapers, or limiting opioids in people living with cancer.

In response to the HP3 letter, CDC Director Robert Redfield merely thanked the organization for its concern and reiterated what the guideline states: that abrupt or involuntary tapering is not what the best evidence recommends. Absurdly, HP3 called Redfield’s letter a “bold clarification.”

Dr. Debbie Dowell, a CDC medical officer and an author of the guideline, also responded to the cancer organizations, acknowledging that previously treated cancer patients were not specifically mentioned in the guideline. Dowell and the two other guideline authors responded to critics in the New England Journal of Medicine in April 2019, again reiterating that “… the guideline does not support stopping opioid use abruptly.”

Their NEJM article does say that misimplementation of the guideline could cause harm — a statement that was immediately spun by Dr. Sally Satel, a co-founder of HP3, as a “forceful and humane variant” of the HP3 letter.

Continuing attack

Criticism of the guideline follows a consistent pattern: no evidence provided to refute any statement in the guideline and no evidence provided for the critics’ claims. The eerily similar attacks on the guideline, and the subsequent spinning of the CDC’s we-meant-what-we-said responses to critics as some kind of admission of error or inadequacy, raise the question of whether this is a coordinated attempt by opioid manufacturers to use third parties to undermine, discredit, and smear the guideline.

There’s certainly a credible motive for opioid manufacturers to do this: The CDC guideline is an effective, evidence-based tool that has helped decrease inappropriate and dangerous prescribing of opioids for chronic pain patients.

Here’s the next line of attack on the CDC guideline: a competing report on opioids and pain management by the Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force. This report opposes many of the CDC’s recommendations and devotes an entire section to criticizing the CDC guideline. The task force includes many nongovernment members financially tied to opioid manufacturers — conflicts comprehensively outlined in a letter by Sen. Ron Wyden (D-Ore.), the ranking member of the Senate Finance Committee.

Letters of protest about the task force’s non-evidence-based draft report included a strongly worded letter from 39 attorneys general stating pointedly, “While this crisis continues, it is incomprehensible that officials would consider moving away from key components of the CDC Guideline …” Nonetheless, the task force overwhelmingly voted to approve a final draft on May 9, 2019. The final report was released on May 30.

A government-funded report that opposes the CDC opioid prescribing guideline is a major coup for opioid manufacturers. The fact that organizations and individuals funded by opioid manufacturers have stepped up their protests of the guideline in recent months is probably not a coincidence.

Opposition from chronic pain patients

Chronic pain patients have also criticized the CDC guideline. Most of the more than 4,000 comments the CDC received during the open comment period were from individuals. Although most chronic pain patients are not being paid by industry, their stories may be used by organizations paid by industry to advocate for doing away with recommended limits on opioid doses or duration.

Pain patients are important to opioid manufacturers because the bulk of opioids are consumed by people living with chronic pain. A crackdown on opioid pill mills has left many pain patients without access to the opioids they depend on, and finding a new physician willing to supply high-dose opioids is difficult. So-called legacy patients who are dependent on opioids certainly need access to these medications. They also need specialized care to taper down from dangerously high doses and multimodal pain treatment. But their advocacy for unlimited access to opioids for themselves may be used to justify new, ongoing opioid prescriptions for chronic pain patients — who will then become future generations of opioid-dependent patients.

As far as real solutions for the opioid epidemic, the authors of the CDC guideline offer one in their NEJM article: “Starting fewer patients on opioid treatment and not escalating to high dosages in the first place will reduce the numbers of patients prescribed high dosages in the long term.”

It is essential that we not abandon patients on long-term opioids — but it is also important that we not create more of them. Opioid manufacturers stand to lose substantial profits with the widespread adoption of the CDC guideline. Public health, however, benefits from the guideline, and attacks on it bear industry’s fingerprints.

Ben Goodwin is a research assistant at PharmedOut, a research and education project at Georgetown University Medical Center. Judy Butler is a research fellow at PharmedOut. Adriane Fugh-Berman, M.D., is the director of PharmedOut and a professor in the department of pharmacology and physiology and the department of family medicine at Georgetown University Medical Center. She also serves as an expert witness at the request of plaintiffs in cases regarding pharmaceutical marketing practices.

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  • “The availability of pills on the street should not be there. This is what we are trying to stop.”
    No matter who it hurts?
    “The last two are due to overprescribing by doctors.”
    That is so false in the current opioid hysteria it borders on delusional.

  • Dr Lawhern – The study by NIH does go on to say 3 sources: prescribed by a doctor; the family medicine cabinet; friends. The last two are due to overprescribing by doctors. The availability of pills on the street should not be there. This is what we are trying to stop.

    • Janet, availability of pills on the street is partly a consequence of over-supply that goes unused, and more often an outgrowtn of rare pill mills.

      Science is simply not precise enough at present to give us rules for numbers and strength of medical opioids that will be adequate for each individual patient and medical condition, given the wide range of opioid metabolism between individuals. Another factor contributing to uncontrolled supply is unjustified fear of addiction on the part of patients, who frequently terminate use of pain medication prematurely. This represents an example of under-medication, not over-prescription.

      Two major US studies demonstrate beyond any reasonable contradiction that exposure to medically managed opioids generates very little risk to legitimate medical patients prescribed opioids post-surgery. Both studies addressed cohorts of over 650,000 patients, followed for periods up to one year in one case, and an average of 2.5 years in the other. Risk of diagnosis for opioid use disorder was a maximum of 0.6%, and likely included many misdiagnoses due to the poor training of general practitioners who most often rendered that diagnosis. In 11 common surgical procedures, incidence of chronic prescribing (continuous prescriptions over 120 days) was less than 1% overall, compared to incidence in non-surgical patients of 0.136%. Further, incidence of chronic prescribing did not rise in 4 of 11 of the procedures, and was a maximum of 0.69% in the procedure most likely to generate protracted pain (total knee replacement). It is entirely plausible that much of this chronic prescribing proceeded not from misuse of medical opioids, but from procedure failures and emergence of chronic pain.

      Thus if I may be candid: what you are proposing to do, Janet, is to damage the lives of up to 99.4% of all patients by limiting medical exposure to opioids that are rarely a cause of addiction in a maximum of 0.6% who may possibly be vulnerable. This is not a shining example of good medical practice.

    • Richard, you have explained this quite well.
      Janet- I fully support your efforts to shut down the pill mills & their criminal “doctors”. They are a scourge.
      People with chronic and/or intractable pain and cancer patients have been and are continuing to be harmed by the lies and misinformation being spread by the authors of this article,the CDC, the DEA, paid shill and self-appointed opioid “expert” Kolodny, PROP and many others.
      The PDMP’s being put in place nation wide are a gross violation of pain patients rights.
      The DEA making medical decisions is a sad joke with no punchline.
      Pain patients are being forced to go to pain clinics where dubious and dangerous procedures are being forced on them in order to get their pain medicine. Patients have to agree to urine samples, pill counts, demeaning “pain contracts” and other unnecessary rules just to receive a legal & safe medicine. No other patients are being forced to go through this idiocy.
      Addicts have access to bupe (an opioid) or methadone (also an opioid) as part of their MAT.
      Pain patients are just having their meds taken away and are offered a bunch of “treatments” that don’t work as well and are often are harmful as well as being far more dangerous than the very small risk of addiction.

  • Dan – The National Institute of Health (NIH) has research that backs up what I stated 8 of 10 heroin users started with not so innocent pain pill. “Prescription opioid use is a risk factor for heroin use” NIH. Do these facts matter?

    • Importantly, no where do they state whether the were diverted Rx’s or for the person they were prescribed for. This was also “self-reported” by addicts so it is hardly a “fact”
      Also from your NIH article-
      “Heroin use is rare in prescription drug users”
      “less than 4 percent of people who had abused prescription opioids started using heroin within 5 years”
      “less than 4 percent of people who had abused prescription opioids started using heroin within 5 years”
      “Prescription opioid abuse to heroin use, cocaine use to heroin use (to “come down”), and polydrug use (i.e., use of multiple substances) to heroin use. Polydrug use to heroin was the most common path in this study (Kane-Willis, et al., n.d.). The estimated 4 percent subset of people who transition from prescription opioid abuse to heroin use (Muhuri et al., 2013) may be predisposed to polydrug use, and the transition may represent a natural progression for them.”
      “Heroin use is rare in prescription drug users”

    • Janet, you and I may have seen different sources of the statistic you are quoting out of context. I believe that the National Survey on Drug Use and Health [SAMSA] reports that about 75% of all heroin addicts interviewed in 30-day resident detox facilities have indicated that a prescription was the first opioid they abused. But NIDA and other sources inform us that 90% of this 75% weren’t prescribed such meds by a doctor. The same people also abused alcohol or marijuana well before beginning an involvement with prescription opioids. Moreover, we know that when a prescription opioid is found in postmortem blood tox screens, perhaps 80% of the time it is found in combination with illegal street drugs, alcohol, and/or benzodiazepine drugs. And it should be obvious that drugs stolen from a home medicine closet will not be available in sufficient quantities to actually get most people seriously habituated, much less “addicted”. So this picture is much more complex and nuanced than many anti-opioid advocates represent it.

      My position, grounded on a lot of study from authoritative sources, is that we do have a drug diversion problem in the US — one that is dominated by knowing corporate diversion of pills into zip codes where there is no possible medical market. See the Washington Post and CBS 60 minutes expose’ last year on the misbehavior of McKesson and the refusal of DEA and DoJ prosecutors to aggressively pursue that company.

      As for medically managed prescription drugs somehow “leading to” heroin, get serious. It may happen in a tiny number of cases (on the order of 1% of all patients), but it is not even remotely “representative” of the core of the US addiction problem. That core expands around people being made vulnerable to substance abuse of all kinds by desperation and depression in high-poverty regions, broken families, and communities hollowed-out by economic stagnation. America’s “opioid epidemic” is one of hopelessness, not medical exposure. And it is considerably larger than a few Billion dollars in addiction treatment programs is going to solve.

      Regards,

    • Janet, that might be possible, but I am 62, a product of latchkey kids in South Memphis. I have known lots of addicts. I remember where people got their drugs.
      In the 80’s and early 90’s doctors were very careful with narcotics. But parents weren’t. Kids were bored and got into parents medicine cabinets, or got them from friends. I do not recall but 1 person ever getting addicted to their pain meds that resulted into true addiction. As I said before, addiction is mental, not a physical disease. It requires action on your part, just like any other addiction.
      I couldn’t care less what the numbers say. Anyone can manipulate numbers.
      Tylenol kills people, penicillin kills people, as a matter of fact, everything has the potential to be deadly under the right circumstances.
      My rods broke in my back in April. I had anterior and posterior instrumentation implanted in my spine 6 weeks ago. I have pain meds right now, true enough, but I have spent the day in bed crying because the pain is so bad and my meds aren’t working.
      If I am to understand you, you have no compassion for people like me? You would rather look at the numbers and make me a statistic rather than allowing me to have any kind of life at all? Especially when there is so much help for addicts right now? I never broke the law, I never stole for drugs, I never beat up my family in a drug induced rage, but my ex, the addict, did.
      I so appreciate your humanity.

    • Judie, thank you for so succinctly stating what I was thinking. People like Janet seem to only see research and numbers, which, by the way are pretty much incorrect. They forget that human beings are living with true agony, day in, day out because of all this. And unless you live this agony there is no way to communicate it to another. I wish there was. I wish there was a technology that could place people like her, who have obviously never felt real pain, into our bodies for a few days. Maybe then they would see and feel the torture they are causing. Since when did torture become legal in America? I am sorry, there will always be addicts. If they didn’t steal pain pills from their parents, they would have been introduced to that high some other way. It is a choice! I could go on and on, but I think everyone who has commented has pretty much covered it all. But shame on you Janet, and all who think as you do. You are condoning torture. And as much as I hate that I feel this way, I can only hope you will feel this agony one day soon and not have access to the only thing that would give you relief.

  • I still remember number two above and many other injuries years after like so many others, tim…people like you mention above have to be some of the most pathetic human beings alive for trying to take away opioids from suffering patients.

    • Johnny Louis, “tim…people like you mention above have to be some of the most pathetic human beings alive for trying to take away opioids from suffering patients.”
      I have never proposed that opioids be taken away from anyone. I think you are looking at the wrong post. I presented a peer reviewed scientific article about which type of opioids work better for intractable pain and the associated rescue opioid recommended for concomitant use. Look at any opioid drug insert and you will see that concomitant use of benzo class is ok when other drugs are ineffective. The ineffective drugs are SRIs, SSRIs and TCAs which will now carry a boxed warning for use with opioids because they can and do cause Serotonin Syndrome.

  • This is well known and written by pain physicians. suboxone is NOT for intractable pain nor is any formulation that has naolxone in it. Read for yourself.
    Chronic pain, intractable pain and cancer pain requires agonist ONLY. The tables in this article a valuable. It also speaks of the need for rescue meds or break through pain meds. Something no one is talking about because they lack intelligence. This fiasco needs to be kicked up a notch immediately. Kolodny and Jayne and the rest of PROP need to be in front of congress NOW.
    https://www.cancernetwork.com/palliative-and-supportive-care/alternative-algorithm-dosing-transdermal-fentanyl-cancer-related-pain/page/0/1

    • Rock solid responses Dan, Judy and many other pain patients and advocates. Something else that’s really offensive to me is how so many addiction specialists and parents of drug abusers who overdosed and/or died have shown such reckless disregard for us pain patients with their speech and actions. They have absolutely no right to disrespect us like alot of them do.

  • I have read some horrible things on behalf of mankind here towards other human beings. Here are some facts: In the latest ME report for the state of Florida. Total deaths from Oxycodone 1,282; cause of death – 610 present -672. Next Hydrocodone total deaths 732; cause of death – 226 present – 506. And Fentanyl total 2088; cause of death – 1743 present – 345. You should be able to see we still have a problem. I can tell you before the advent of the “pill mills” heroin and fentanyl was almost non-existent in Florida. 8 of 10 heroin users start with the not so innocent pain pill. Read the book STOPPNow. You might learn something.

    • The problem here is we each have our own agenda. I take it you are totally anti-opiate because you are looking at one group of people. Those people are important and there are millions of them: addicts who cannot control their impulses to get high and they are killing themselves.
      Society says someone must be blamed! Someone must pay the price! So if you get rid of all the opiates, people won’t be able to OD. But that isn’t true.
      Addiction is a mental illness, not a physical one.
      I know this because I had to taper myself off all opiates, I didn’t have a problem, and no one told me how. I am not special. I just do not feel euphoric when I take pain meds; they make me sick, but I thank God I have them every day.
      We people with intractable pain can no longer enjoy any kind of life. Lock yourself in your house for just 1 week. Imagine every waking minute something in your body hurts to the point it brings you to tears. But people who you trust to heal you laugh at you, scoff at you, call you a drug addict, doctors won’t see you and everyone questions your motives.
      All I am asking is you consider both groups of people. Because at the rate we are going, more and more people are going to die, and either way it’s going to be horrible. And it already is.
      I am truly sorry you have so little compassion for people in pain. If you were in our place, you would think quite differently.

    • 1. Below are the Florida stats from the same report. These are deaths where only 1 opioid was present (like the Rx’s for pain medicine that most chronic pain patients have). Please note how low those numbers are compared to the “total deaths” numbers you’ve provided.
      Deaths with Oxycodone Only
      106 29 77
      Deaths with Hydrocodone Only
      108 11 97
      Deaths with Fentanyl Only
      163 126 37
      Deaths with Morphine Only
      96 28 68
      Deaths with Heroin Only
      9 9 0
      2. As I and many of the commenters have noted, most drug OD’s are poly drug related.
      btw ethanol is listed as present in 5,258 deaths, by far the leading drug present
      3. The report does not break deaths down by Rx meds USED AS PRESCRIBED or used for suicide
      4. As terrible as these deaths are, they provide zero justification for treating chronic pain and cancer patients like criminals or for taking away their medicine that works. Even the anti-opioid CDC states that addiction occurs in .62% to 2% of all patients prescribed opioid medicine
      5. Overdose death rate for patients with Rx opioids taken as prescribed is almost zero
      6. Kolodny & PROP are addiction “specialists” . They aren’t involved in pain care. Jane Ballantyne of PROP has said that pain patients need to stop opioid medicine and just get “used to” their pain.
      7. I could go on but I and others have made it clear why they have no love for these unqualified people interfering in the doctor/patient relationship & attempting to demonize safe and effective pain medicines
      8. Lastly, you stated ” 8 of 10 heroin users start with the not so innocent pain pill”. This is not true.

  • Severe, constant pain must be experienced to be understood. Like War or Combat. Also, it is not just CHRONIC PAIN. There is INTRACTABLE PAIN which 10% of the population suffers from is being lumped under one umbrella of Chronic Pain. You cannot know what it feels like to suffer from the following if you have never experienced it:
    1. Being shot
    2. Being Hit by a car
    3. Having bone cancer or any cancer
    4. Being raped
    5. Being mugged without warning
    6. Having your house burn down
    7. the list could go on and on.
    Even the likes of Andrew Kolodny and Jayne Ballentyne do not know how it feels to have INTRACTABLE PAIN.
    Neither do they know what level of Scheduled II opioid reduces this pain. So how on God’s green earth can they make decisions about pain treatment with Rx opioids when they have no skin in the game? They aren’t even pain doctors. They are consultants set out to make money by calling everyone an addict. BS! There is a difference between dependence and addiction. Not unlike a diabetic is dependent on insulin. We do not say he is addicted to it now do we? What an absurd thought. Pain medicine for intractable pain and cancer pain is no different. It is just the ignorant of some people that do not know that they do not know. We have names for these people. DAs.

  • I offer further observations for the authors of this PROPaganda piece and for patients and physicians who have commented earlier in this unusually active thread.

    Be aware that the authors have already lost the argument. They simply don’t want to acknowledge their own misrepresentation. Here is pertinent evidence:

    In November 2018, the American Medical Association House of Delegates met as they do yearly. Among other resolutions they released, was #235 — which is truly ground breaking. I quote it exactly here:

    “RESOLVED, that our AMA affirms that some patients with acute
    or chronic pain can benefit from taking opioid pain medications
    at doses greater than generally recommended in the CDC
    Guideline for Prescribing Opioids for Chronic Pain and that such
    care may be medically necessary and appropriate, and be it
    further

    “RESOLVED, that our AMA advocate against misapplication of
    the CDC Guideline for Prescribing Opioids by pharmacists,
    health insurers, pharmacy benefit managers, legislatures, and
    governmental and private regulatory bodies in ways that
    prevent or limit patients’ medical access to opioid analgesia,
    and be it further

    “RESOLVED, that our AMA advocate that no entity should use
    MME (morphine milligram equivalents) thresholds as anything
    more than guidance, and physicians should not be subject to
    professional discipline, loss of board certification, loss of clinical
    privileges, criminal prosecution, civil liability, or other penalties
    or practice limitations solely for prescribing opioids at a
    quantitative level above the MME thresholds found in the CDC
    Guideline for Prescribing Opioids.”

    AMA has since posted a further strengthening of this resolution in AMA Board of Trustees Report 22 which reads in part,

    “That our AMA oppose the use of “high prescriber” lists used by national pharmacy chains, pharmacy benefits manager companies, or health insurance companies, when those lists do not provide due process and are used to blacklist physicians from writing prescriptions for controlled substances and preventing patients from having their prescriptions filled at the pharmacy of their choice.”

    On another front, be aware also that the American Academy of Family Physicians and five other professional academies and associations representing ~650,000 physicians and medical students, have jointly published another repudiation of the horrid consequences of the CDC guidelines, as follows: ‘Frontline Physicians Call on Politicians to End Political Interference in the Delivery of Evidence Based Medicine’. See https://www.aafp.org/media-center/releases-statements/all/2019/physicians-call-on-politicians-to-end-political-interference-in-the-delivery-of-evidence-based-medicine.html

    Finally, a note from the State of Washington. Their State Medical Commission on March 8, 2019 published an “Interpretive Statement” which includes the following wording:

    “The opioid prescribing rule states that appropriate pain management is the responsibility of the treating practitioner and the inappropriate treatment of pain, including lack of treatment, is a departure from the standard of care. The Commission… encourages practitioners, especially those in primary care, to view pain management as a part of standard medical practice for all patients and to become knowledgeable about assessing pain and effective treatments. The intent provision explicitly states that the rules are not inflexible and repeatedly recognizes the importance of clinical judgment.
    The Commission interprets …[several named standards documents]… as encouragement to practitioners to not exclude, undertreat, or dismiss a patient from a practice solely because the patient has used or is using opioids in the course of normal medical care. While in most circumstances a practitioner is not legally required to treat a particular patient, the refusal to see or continue to treat a patient merely because the patient has taken or is currently using opioids is contrary to the clear intent of the Commission’s rules governing opioid prescribing. Ending opioid therapy or initiating a forced tapering of opioids to a particular MED level for reasons outside of clinical efficacy or improvement in quality of life and/or function or abuse would violate the intent of the rules.”

    Without injecting too much into this statement, I look forward to hearing about malpractice lawyers who will apply it as evidence in hospital or practitioner discharges of patients refused adequate pain care.

    I suggest that the tide of misinformation spread by fringe element anti-opioid zealots like these authors has peaked and is now ebbing. My own work (recently shared with the Washingon Medical Commission) may contribute to this reversal of course in some central way. Using CDC published data, I have demonstrated that rates of opioid mortality have no relationship at all to rates of doctor prescribing for medically managed opioids. NONE, zip, nada. If someone wants to argue this case, then argue with the data, not with me. An analysis report integrating the CDC data may be downloaded from

    http://face-facts.org/atip/analysis-of-us-opioid-mortality-and-er-visit-data-v15-april-2019/

    To close: be aware that I am working on model legislation to be introduced in the Congressional markup cycle this summer, rendering AMA Resolution 235 as mandatory regulatory policy for all Federal healthcare and law enforcement agencies. Comment is invited via lawhern@hotmail.com

  • “About 17,000 people die each year in the US from a prescription opioid overdose.” according to the CDC.
    In reality, the overdose death rate from legal Rx opioid medicines taken as prescribed is almost non-existent. The lowest rate is 55-64 y.o who are Rx’ed the MOST opioids (also from the CDC)

    The CDC lies about the Rx opioid medicine death rates. These are fentanyl & heroin deaths (and other illegal drug use) not Legal Rx opioid medicine. Most deaths that involve Rx opioid medicine are either diverted (stolen) Rx’s or polydrug use like hydrocodone, alcohol, tranquilizers and/or sleeping pills. Or the patient was terminal and just died from their illness. And, yes, the fact-impaired CDC and the DEA para-military thugs DO count this as an opioid death

    The CDC and DEA double count or more on so-called opioid deaths
    If 1 person dies & has heroin, fentanyl and alcohol present in their blood and they die in a car crash, then they count that as:
    1 heroin death
    1 fentanyl death
    1 alcohol death
    1 auto fatality due to drugs & alcohol
    That’s 1 death counted 4 times

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