Prescription Drugs

CDC Prescription Guidelines Will Leave More Patients in Pain and Drive More Addicts to Heroin

To shrink the supply of opioids, the agency encourages doctors to be suspicious and stingy.



Yesterday the U.S. Centers for Disease Control and Prevention (CDC) released prescription guidelines for family doctors aimed at reducing nonmedical use of opioid painkillers and the harm associated with it. The guidelines, which are officially nonbinding but can be expected to affect regulators' judgments, malpractice liability, and insurance coverage decisions, include some sensible precautions, such as warning patients against mixing opioids with other depressants, avoiding dual prescriptions of opioids and benzodiazepines when feasible, and providing naloxone, an opioid antagonist that reverses the effects of an overdose, to patients taking large amounts of painkillers. But the overall message sent by the guidelines and several of the CDC's specific recommendations inevitably will impede access to narcotic painkillers by legitimate patients who would benefit from them.

The CDC urges doctors treating acute and chronic pain (except in cancer patients or people near death) to view opioids as a last resort. They are supposed to first try nonpharmacological treatments and nonopioid painkillers such as ibuprofen and acetaminophen. That's fine if the other approaches work as well. But doctors who internalize the CDC's overwrought concerns about addiction and overdose (more on those in a minute) will be inclined to avoid opioids even when the alternatives are only half as effective, leaving patients to suffer unnecessary pain. 

The CDC wants doctors who are already inclined to treat patients complaining of pain with suspicion to be even more leery. It recommends interrogation and urine testing aimed at discovering illicit drug use, ostensibly to inform clinical decisions. It does not explicitly say that someone who, say, admits consuming cannabis or tests positive for it should be denied the drugs he needs to control his pain, but you can be sure that will be the result in some cases.

"Clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids," the CDC says. "Three days or less will often be sufficient; more than seven days will rarely be needed." Since pain cannot be objectively verified, what counts as an "effective dose" or a "needed" quantity depends not only on the patient's report but on the doctor's willingness to believe it. The CDC is encouraging doctors to be more skeptical of patients' reports and to substitute their judgments for those of the people who are actually experiencing the pain. That tendency, combined with the arbitrary limits on pill counts, will mean more needless suffering.

"While we are largely supportive of the guidelines," says the American Medical Association, "we remain concerned about the evidence base informing some of the recommendations, conflicts with existing state laws and product labeling, and possible unintended consequences associated with implementation, which includes access and insurance coverage limitations for non-pharmacologic treatments, especially comprehensive care, and the potential effects of strict dosage and duration limits on patient care." The consequences for patient care may be unintended, but they are entirely predictable.

"If [the CDC guidelines] produce unintended consequences," the AMA adds, "we will need to mitigate them." That will not be easy now that the pendulum is swinging toward drug control and away from pain control. "These [guidelines] will not be seen as voluntary," notes Myra Christopher, director of the Pain Action Alliance to Implement a National Strategy. "These will become the definition of the standard of care, because of the clout of the Centers for Disease Control."

The official justification for exercising that clout is the need to curtail the "epidemic of prescription opioid misuse and overdose," which according to the CDC killed more than 165,000 Americans between 1999 and 2014—around 10,000 a year on average. That sounds like a lot, but it's a tiny percentage of the people who received opioid prescriptions during that period. The CDC says "health care providers wrote 259 million prescriptions for painkillers in 2012, enough for every American adult to have a bottle of pills." On the face of it, 10,000 or so deaths out of 259 million prescriptions—one for every 26,000—do not amount to a very big risk.

The same goes for addiction. According to the National Survey on Drug Use and Health (NSDUH), a bottle of opioids for every American adult resulted in about 2 million cases of "abuse or dependence" in 2014, or one for every 130 prescriptions. The rarity of abuse or addiction should come as no surprise to the vast majority of Americans who have taken Vicodin or Percocet for pain. Maybe you enjoyed the buzz, but odds are you did not continue taking painkillers every day once your pain was gone. The truth is that using such drugs regularly for their psychoactive effects appeals to only a small minority of people, which is one reason heroin has never been very popular even among illegal drug users. "We lose sight of the fact that the prescription opioids are just as addictive as heroin," says CDC Director Thomas Frieden. In other words, not very.  

The risk of addiction for pain patients is even smaller than these numbers suggest, because most nonmedical opioid users do not start as pain patients. According to NSDUH, only a quarter of people who take opioids for nonmedical purposes get them by obtaining a doctor's prescription. Most (66 percent) get them from a friend or relative, usually for free by asking, sometimes surreptitiously and sometimes in exchange for money. Another 5 percent buy opioids from a dealer or other stranger. Theft, fake prescriptions, the Internet, and "other" account for the rest. Hence the sequence that many people imagine—a patient takes opioids for pain, gets hooked, and eventually dies of an overdose—is far from typical of opioid-related deaths.

Opioid-related deaths are rare even for patients who take narcotics every day for years. The CDC cites "a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain" who were followed for up to 13 years. The researchers found that "one in 550 patients died from opioid-related overdose," which is a risk of less than 0.2 percent. Furthermore, that risk is not random, since deaths attributed to opioids generally involve combinations of two or more drugs. 

Discouraging such dangerous mixtures, combined with wider availability of naloxone, would help reduce the number of deaths involving prescription opioids and heroin, which hit a record high of 29,467 in 2014. Cracking down on painkillers, by contrast, will only drive more prescription opioid users to heroin, which exposes them to more danger. "In the case of heroin," observes Norah Volkow, director of the National Institute on Drug Abuse, "this danger [of poisoning] is compounded by the lack of control over the purity of the drug injected and its possible contamination with other drugs (such as fentanyl, a very potent prescription opioid that is also abused by itself). All of these factors increase the risk for overdosing, since the user can never be sure of the amount of the active drug (or drugs) being taken."

As a strategy for reducing opioid-related harm, shrinking the supply by making prescriptions less generous and harder to get sacrifices the lives of current users to protect future users. As is generally the case with drug prohibition, the beneficiaries of this paternalism are not the people who bear the cost. The same is true of legitimate pain patients who will suffer as a result of the government's attempt to prevent others from becoming addicted. Regardless of whether they "work" from a prohibitionist perspective, such tradeoffs are inherently unethical.

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  1. No mission creep there at all.

    1. Addiction is a disease, after all.

      1. And quite contagious, just like fat

        1. Look, just because I announce it's "shot o'clock" doesn't mean you have to partake.

    2. Not only is it mission creep, it actually fails to even address the base mission. Drive people into heroin use, and they're more likely to transmit diseases. In government, nothing succeeds like failure.

      1. If only there were some consistent principal which would guide them to the conclusion that neither guns nor prescription of painkillers is their business. Researching infectious diseases, period.

  2. Great. More deaths by overdose and suicide.

    But remember, the government is there to help!

    1. Without government, who would...?

    2. But, you see, that pumps up the need for government funded "services" like courts, prisons, drug "treatment" and suicide prevention.

  3. plus ?a change...

  4. nonopioid painkillers such as ibuprofen and acetaminophen

    Wouldn't someone seeking treatment for severe pain already have tried these?

    1. You think doctors are going to take the word of a filthy junkie?*

      * Per CDC guidelines, anyone needing painkillers is to be presumed a junkie at all times

    2. Absolutely. And they are completely ineffective against severe pain. Acetaminophen will also cause liver failure in latger doses. But people need to suffer unnecessary pain because someone, somewhere, could possibly be getting high. And we can't allow adults to be responsible for choices about their own bodies.

      1. latger = larger

        1. Acetaminophen will especially damage the liver in lager doses!

      2. Acetaminophen will cause liver failure in small doses over long periods, too. It's a significantly more dangerous drug than any opiate, by the numbers. But if someone dies after taking Vicodin, the CDC chalks it up as an opiate overdose.

    3. High doses of NSAIDs can cause GI bleed and require hospitalization and blood. But hey, somebody could get high somewhere so screw them.

      1. High doses of NSAIDS gave me stomach ulcers that kept recurring for years.

  5. Gov. Baker in MA just the day before signed legislation on this very subject. The core concept is to write smaller does for acute situations. Having had shoulder surgery and back issues, denying legitimate pain medication should be considered malpractice itself - although I'd suggest on the part of the politicians. (p.s. I didn't get hooked after the first pill, and I doubt most people do. The warning that I was given was to "stay ahead of the pain"; i.e. don't try to be the strong silent type and tough it out. )

    The problem with the CDC is their one size fits all attitude and their certainty that today's recommendations are the last word on the subject.

    1. The real problem with the CDC is that controlling drug addiction isn't even part of their mandate

      1. The CDC needs a continuous supply of communicable disease in order to grow their budget. Junkies help the CDC in that regard.

    2. When I had shoulder surgery, the surgeon gave me several post-dated scrips for Vicodin (daytime) and Percocet (nighttime), staggered about every 4 days. It was a great way around this bullshit, but it's sad that he either had to do that or make me come in weekly to renew them. And I hope he never gets turned in for doing that. I still have several of the percs just in case.

    3. Yes, the last word I heard was that taking enough of a narcotic analgesic to keep the pain from coming back reduced the chance of developing psychologic dependence on the drug. Apparently pain is such a strong negative reinforcer that abolishing it works to keep the patient from developing an attachment to pain relief.

  6. With due respect, Sullum, your fucking lines above drip into my cognition as nothing more than acronumbificated shrieks. Capital letters standing next to each other are thorned walls concealing the misdeeds of institutional elitism. Skinless revelations are apparitions dancing in the moonglow of humanity's delusion.

    ALL fucking acronyms that federalize cruelty are home to human products. Desperate professionals bearing minds quivering with grand strategies to subjugate the natural impetus of societies and scenes should be revealed in the greatest depth possible.

    The stony temples of shouting letters are fortresses engineered to resist and divert into impassive pools the raging organic rivers of humanity.

    Pry back the mountain to reveal the dragons.

  7. Since pain cannot be objectively verified

    Yeah, so, where are we on that? EEG, FMRI, something has to be able to register activated pain receptors.

    "Jesus, this guy's pain center is lit up like a christmas tree, dope him up, STAT!"

    1. Thus the headline that keeps cropping up in my Google News aggregator -- 'Zero pain is not the goal'.
      Why fucking not? It's *my* goal.
      We're going to have to change that (offensive) T-shirt slogan -- Pain is the Government controlling your body.
      It's not weakness leaving, that's for damn sure.

      1. "My body, my choice" ...oh, wait....

      2. 0 pain used to be the official goal.

        1. which is ridiculous.

    2. The problem with that, I think, is that pain is the subjective psychological experience and has to do with more than the activation of pain receptors. You may be able to see what someone's nerves are doing, but you still can't tell how they feel.

      1. Pain is very subjective. Part of it is cultural and part of it is individual.

      2. It's part of the whole mind-body problem. There's obviously some relationship between mind & body, but nobody can prove which way the causality flows, nor say anything for sure about non-bodily mental processes.

  8. This situation is already bad. My mother spent the last years of her life in agony because of this bullshit. Castrate all of these fuckers with a dull rusty spoon.

  9. Killer legislation, literally.

    Been through this with a very close friend. After suffering from chronic and acute pain over an extended period of time, which his doctors failed to medicate properly, he committed suicide.

    1. Omelets, eggs, comrade. Government is just the people we drive to suicide together.

  10. I was talking with someone the other day about the subject of restrictions on prescription opioids and I think I actually convinced him that it was more important to give people the treatment they need for pain than to prevent some people from getting high for fun and that all drugs should be legalized.

    1. My pharmacist brother often bitches about people with high dosage opioid prescriptions, mostly because the extra administrative work he has to go through. I always reply, "Why do you give a fuck if people wanna get high? You think government has EVER been successful in stopping that?" His answer is usually good, though: "I don't give a shit if they wanna get high. I give a shit because it's fucking up the insurance companies. Everybody would be better off if the stuff was OTC, but it's the assholes that don't want to pay for their own high fucking it up for the people that actually NEED the pain relief."

      He's right. Which ought to make everyone despise pieces of shit like Sandra Fluke even more.

      1. He should be bitching about the DEA, not the people with prescriptions.

  11. Addiction starts not with legit prescriptions, but by begging, borrowing, or stealing someone else's. That's right: after they tell you "don't do drugs" a thousand times you do it anyway, and this results in a 'disease' that makes you do things they just told you not to do. I feel really bad for pain patients, and some will kill themselves as a result of this decision, and the CDC will use their deaths as further 'proof' of opiate addiction and the need to restrict them further. Here's the problem: the addict kiddies can get 'hooked' on half a pill. And they will tell you that at their meetings. So this brings me to my final point: if you want to break the back of the addiction theocracy, just attend your local AA/NA meeting and observe with a skeptical eye. Otherwise, stop bellyaching (and blaming everyone else for your problems).

    1. "Breaking the back of the addiction theocracy" reminds me of my young adulthood hobby of tearing down the tenets of someone's faith- then offering absolutely nothing in return.

      As an guy who's 11 years sober after going thru the 12 step process, I share your skepticism in meetings. Mine isn't because of the disease concept, its because most meetings are filled with proselytizing assholes who treat the fellowship like an aristocracy where your rank is based on the number of days sober you've tallied.

      The only applicable conclusion for the addict in regards to the disease concept is to avoid the first drink or drug. It speaks only to addicts who fall into the "chronic" category and doesn't apply to "hard" drinkers who make up most of the people who attend meetings. `

      1. LOL thanks for making my point - 'addiction' is a religion for idiots. Like I said, attend your local meeting and see for yourself. Otherwise, you have only yourself to blame.

        1. I was likening your aim to discredit the disease theory to my (rather revolting) practice of stripping people of their religious faith. Strip away that "myth" and we'll still have a small segment of the population who dies as a result of substance abuse, as has been the case since man learned how to crush the grape.

          You may be right about the disease concept being bunk, but I think it would be foolish to throw the baby out with the bathwater and reject the most (by far) successful treatment for overcoming substance abuse.

          1. In all honesty, you probably never actually stripped anyone of their faith. Young adults tend to massively overvalue their own powers of persuasion.

            1. Definitely agree and was guilty of said overvaluation. Though I was able to back some people into a corner, I'm quite confident that they later decided I was just an asshole and didn't change their thinking.

              Shitting on the 12 step process by attacking the disease theory is much more likely to have an effect, though. Virtually nobody comes into AA ready to admit to and face their resentments, fears, the harms they've done to others and ruthlessly set out to make it right-- the work that solves the problem.

              1. That's true. Attacking AA is not going to help anything. Even if it's only 5% successful at getting attendees sober, that's still a much higher percentage than any kind of forced rehab.

                1. In the foreword to the 2nd edition of the book Alcoholics Anonymous they claimed that of those who came to AA and "really tried" (which I take to mean that they commenced the 12 step process) 50% sobered up immediately and stayed that way, 25% after some relapses.

                  The numbers I've seen in AA today are much lower, more to the tune of ~15%. I suspect its the degradation of the meetings into a form of half-assed group therapy rather than a place for new people to find a guide to take them through the steps (and for older members to find new members to mentor them through the steps.)

                  When I was in treatment 15 years ago, the statistics said that of those who successfully completed a long term rehab (90 days or more,) 3-5% were sober 5 years later. Pretty shitty odds- I've buried a dozen people under the age of 30 since I've been sober.

    2. I've never heard anyone say they got hooked on half a pill except Patrick Kennedy.

      1. Of course no one really gets "hooked" on half a pill (though there are some pretty damn strong pills that could last a novice user a few days). But I'm sure many take the half-pill, like it a lot, and keep going until they are hooked.

  12. Severe pain causes other problems besides suicide. It raises the heart rate and increases adrenalin in the blood which can cause still more problems. Pain can make daily activities difficult because it overwhelms one's thinking, similar to having someone shouting in your ear. It's a nasty condition or disease that should be a priority rather than anathema.

    Also, drugs don't addict people. Addiction is a mental/physiological disease that can manifest itself in many ways other than drug abuse. People aren't addicted because of drugs. They abuse drugs because they are addicted.

    1. Addiction is a mental/physiological disease that can manifest itself in many ways other than drug abuse.

      This is key. Too many people talk about addiction as if it is simple cause and effect. Or as if they physical dependence on things like opiates is itself addiction. But there are people who take opiates even to the extent of having bad withdrawal symptoms who don't end up addicts and many junkies can completely go through the withdrawals and still be very addicted.

      1. I agree. If the crux of the issue was the physical dependence then checking into rehab or detox would be the cure. Since 5% who complete impatient treatment are sober 5 years later, its not. I'm certain the problem centers in the mind.

        This explained much for me as a young person failing at sobriety after stringing together a few months here and there. I don't fully comprehend the mechanism, but going through the 12 step process drastically changed me as a person. In many ways, I just matured and was finally able to live in accordance with my morals. The way I reacted to life situations changed inexplicably. My obsession to change how I felt through chemistry fell away seemingly by magic, and I've been sober without struggle ever since.
        Not at all an uncommon experience.

    2. Very true. When I was younger and taking amphetamines for working long hours, I was careful and quit every time things slowed down. Never had trouble finding them. I went through physical withdrawal a couple of times. A couple of miserable days and then over. When I switched jobs, never felt the need for taking them again.

      I've also been in chronic pain for almost 30 years and had prescription opioid painkillers always available, but I don't take them unless I'm hurting enough I can't think straight anyway. Never had any trouble even with physiological addiction, much less psychological. Yet those are the prescriptions my doctor has quit prescribing. I'm hoarding my last few strong ones and worried about the weaker ones because they're Tylenol with codeine and I have to take more than one to get any relief at all.

  13. I seem to be missing a Hat Tip:

  14. A more fundamental question is what Constitutional justification exists for the existence of the CDC or, by extension, the FDA. What's the Constitutional justification for the claimed power of the federal government to tell Americans what they may or may not ingest, inject, inhale into their own bodies?

  15. These statistics are quite surprising. Only 1 out of 550 patient die of opioid overdose. Means only a fraction of patient become addict to opioids and by controlling the opioid prescription, system will force them to heroin abuse. An addict will abuse either oipoid or heroin anyway then why genuine patients need to suffer.

  16. A thought; THE CDC is responsible for only DISEASE CONTROL...CDC has no business directing OPIOID ANALGESIC/Pain control for the people who are diagnosed, by licensed healthcare professional.

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