Last week the American Medical Association took a stand against the "misapplication" of the opioid prescribing guidelines that the U.S. Centers for Disease Control and Prevention published in 2016. The resolution reflects the frustration of physicians who have found that the CDC's advice, as interpreted by legislators, regulators, insurers, pharmacists, and law enforcement agencies, is interfering with treatment of patients suffering from severe pain.
The guidelines were supposedly optional and advisory, but they have become increasingly mandatory as they have been incorporated into laws, regulations, and policies adopted by insurers and pharmacies. The result has been involuntary dose reductions for patients across the country, including people with severe chronic pain who had been functioning well on opioids for years and are now suffering, bedridden, and in some cases suicidal. Particularly damaging has been the CDC's recommendation that physicians "should avoid increasing dosage" above 90 morphine milligram equivalents (MME) per day, or at least "carefully justify a decision to titrate dosage" above that level.
A resolution approved by the AMA House of Delegates last week affirms that "some patients with acute or chronic pain can benefit from taking opioids at greater dosages than recommended by the CDC Guidelines for Prescribing Opioids for chronic pain and that such care may be medically necessary and appropriate." The resolution opposes "the misapplication of the CDC Guidelines for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit access to opioid analgesia." The AMA says "no entity should use MME 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 Guidelines for Prescribing Opioids."
In a speech last week, Pain News Network reports, AMA President Barbara McAneny described her own experience with the damage caused by anti-opioid zeal. When a patient with metastatic prostate cancer was suffering from bone pain that was not adequately relieved by his medication, "I increased the dosage of his opioids from two per day to three, and of course he ran out early," McAneny said. "So I called his primary care physician, who agreed to write a prescription for his very large amount of time-release morphine." When the patient tried to fill the prescription, the pharmacist contacted the insurer, which denied coverage.
"The pharmacist suspected my patient was a drug seeker and did not alert me that his prescription was denied," McAneny said. "My patient, a very proud man, felt shamed and didn't know what to do. So he went home to be as tough as he felt he could be. That worked for about three days, and then he tried to kill himself."
McAneny acknowledged concerns about overprescription and diversion of opioids but suggested the pendulum is "swinging back so far that patients are being harmed." While "I share the nation's concern that more than 100 people a day die of an overdose," she said, "my patient nearly died of an under-dose."