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.