Opioids

Experts Urge CDC to Clarify Prescribing Guidelines That Are Hurting Pain Patients

The agency's opioid advice has led to arbitrary dose reductions, denial of care, senseless suffering, and suicide.

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Yesterday more than 300 experts on pain treatment and addiction, including three former drug czars, urged the U.S. Centers for Disease Control and Prevention to clarify its 2016 opioid prescribing guidelines, which have led to arbitrary dose reductions across the country, depriving patients of the medication they need to make their lives bearable. The guidelines are part of a broader crusade against opioid prescribing that has left patients in agony and driven nonmedical users (as well as some pain patients) into the black market, where the drugs are far more hazardous. Unsurprisingly, the government-driven reduction in opioid prescriptions, which the Trump administration celebrates and wants to continue, has been accompanied by a continuing surge in opioid-related deaths, the vast majority of them involving illegal drugs.

"We urge the CDC to follow through with its commitment to evaluate the impact [of the guidelines] by consulting directly with a wide range of patients and caregivers, and by engaging epidemiologic experts to investigate reported suicides, increases in illicit opioid use and, to the extent possible, expressions of suicidal ideation following involuntary opioid taper or discontinuation," the letter to the CDC says. "We urge the CDC to issue a bold clarification about the 2016 Guideline—what it says and what it does not say, particularly on the matters of opioid taper and discontinuation."

The CDC's guidelines, addressed to primary care physicians, did not endorse involuntary tapering or discontinuation of care for chronic pain patients. But the document strongly implied that dosages exceeding 90 morphine milligram equivalents (MME) per day were dangerous and generally inconsistent with good medical practice. Doctors "should avoid increasing dosage" above 90 MME per day, the CDC said, or at least "carefully justify a decision to titrate dosage" above that level.

As for patients who already exceeded 90 MME per day, the CDC said "clinicians should work with patients to reduce opioid dosage or to discontinue opioids" if they determine that the risks outweigh the benefits. It noted that "tapering opioids can be especially challenging after years on high dosages" but said "these patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages."

This advice was widely interpreted by physicians, pharmacists, insurers, regulators, and legislators as a warning against prescribing more than 90 MME a day, even for chronic pain patients who have functioned well for years on high doses of opioids. "Within a year of Guideline publication," the letter notes, "there was evidence of widespread misapplication of some of the Guideline recommendations. Notably, many doctors and regulators incorrectly believed that the CDC established a threshold of 90 MME as a de facto daily dose limit. Soon, clinicians prescribing higher doses, pharmacists dispensing them, and patients taking them came under suspicion."

Reactions to the guidelines have included statutory limits on opioid prescriptions, "payer-imposed payment barriers, pharmacy chain demands for the medical chart or explicit taper plans as a precondition for filling prescriptions, high-stakes metrics imposed by quality agencies, and legal or professional risks for physicians, often based on invocation of the CDC's authority." As a result, "many health care providers [began] to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care."

The consequences for patients have included "draconian and often rapid involuntary dose reductions," inappropriate addiction treatment, pressure to undergo invasive procedures that may not be medically justified, increased use of illegal opioids as a substitute for previously prescribed analgesics, "unnecessary suffering," and in some cases suicide. "Under such pressure," the letter notes, "care decisions are not always based on the best interests of the patient."

That is quite an understatement, but the letter as a whole is strongly worded and properly puts the onus of action on the CDC, which in 2016 said it was "committed to evaluating the guideline to identify the impact of the recommendations on clinician and patient outcomes, both intended and unintended, and revising the recommendations in future updates when warranted." The fact that the signatories include people with a wide range of views about drug policy—among them Phoenix House founder Mitchell Rosenthal and Jerome Jaffe, Barry McCaffrey, and Michael Botticelli, who served as drug czars in the Nixon, Clinton, and Obama administrations, respectively—speaks volumes about the extent to which the indiscriminate push to reduce opioid prescribing has harmed pain patients.

The letter, which was coordinated by University of Alabama at Birmingham internist Stefan Kertesz and psychiatrist Sally Satel, a fellow at the American Enterprise Institute, includes reports from hundreds of affected patients. It follows similar expressions of concern by the American Medical Association and the Pain Management Best Practices Inter-Agency Task Force, which is advising the Department of Health and Human Services.

Thomas Frieden, who was director of the CDC when it produced the guidelines, seems to think there is no need for clarification or re-evaluation. "What the guidelines are being blamed for versus what they actually recommend are two different things," he told The New York Times.

But as Lynn Webster, a former president of the American Academy of Pain Medicine who signed the letter, told me last year, the CDC, given its status within the medical community, should have foreseen that its advice would be interpreted as a mandate. "The CDC bears full responsibility for how these arbitrary dose levels are being implemented throughout the country and the consequences for the people in pain," Webster said. "I said at the time when they were proposed that if something comes from the CDC as a guideline, it is more than a guideline. It will be interpreted basically as a level of dosing that if you exceed [it], then you are at legal jeopardy."

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  1. It’s amazing how many problems governments create, and how uncaring statists are in the matter. It’s like robbing anybody who reports a robbery, but with a gratuitous shooting or stabbing just because.

    And they say libertarians have no empathy!

    1. It’s amazing how many problems governments create

      Yeah, but you don’t want the SJWs to win, do you?

  2. Even before the fentanyl panic gripped tha teevee newz, I could tell that the hospital was cutting back on its dosage when I had my colonoscopy. It was painful as fuck! I’m still furious with them over it.

    1. You get the midazolam and fentanyl sedation, huh? Ask for the Propofol and get knocked out. It’s great.

      1. Agreed. Propofol is the only good thing about getting a colonoscopy.

        1. Thanks for the tips!

        2. If you use enough Propofol to get knocked out, you’re just that, knocked out. It’s just a regular sleep. No experience.

    2. Not at all funny. What a twit.

      1. My anus howled with laffter.

    3. If you can remember the procedure it’s because you didn’t get enough midazolam (Versed.) Conscious sedation with midazolam has a significant amnestic component.

      But, overall I agree that propofol is (for most people) the way to go. Some people can’t get it though – if you have significant cardiac issues they might make you stick with midazolam.

  3. I just can’t wait for medicare for all. It will be great.

  4. OT:

    In sensitive year for China, warnings against ‘erroneous thoughts’

    China’s ruling Communist Party is ramping up calls for political loyalty in a year of sensitive anniversaries, warning against “erroneous thoughts” as officials fall over themselves to pledge allegiance to President Xi Jinping and his philosophy.

    In late January the party again stressed loyalty in new rules on “strengthening party political building”, telling members they should not fake loyalty or be “low-level red”, in a lengthy document carried by state media.

    “Be on high alert to all kinds of erroneous thoughts, vague understandings, and bad phenomena in ideological areas,” it warned. “Keep your eyes open, see things early and move on them fast.”

    “Thomas Friedman’s mustache grew three sizes that day.”

    1. See, “Mao” is easy to remember, like “Marx”, “Lenin”, and “Stalin”. Who remembers Engels, or Khrushchev, or Andromeda-what’s-his-name, or Xi Jinping once he’s gone? What’s-his-name is barking up the wrong tree.

      1. “Xi” seems to fit in pretty well with the others.

        1. Not with SJWs, who are the only people where it matters. It’s obvious Che was on t-shirts because of his short name. But SJWs will confused Xi for a personal pronoun. I wonder what plural they will come up with.

          Sooner or later, someone would wear a Xi t-short and be brought up for re-education for culturally appropriating Xe’s gender choices.

    2. “Be on high alert to all kinds of erroneous thoughts, vague understandings, and bad phenomena in ideological areas,” it warned. “Keep your eyes open, see things early and move on them fast.”

      Will I be cast into the gorge of eternal peril for noting that the high alert in communist China is not, in fact, a red alert?

  5. Just require anyone needing more than 90 MME per day get vaccinated. I don’t see the problem here.

  6. its 2016 opioid prescribing guidelines

    The Dear Colleague letter for drugs?

    1. My GP put up a sign a couple years ago saying he wont’ give out pain meds for chronic pain any more or after you’ve gone through the amount that a surgeon prescribed for post-surgical pain.

      He told me it’s just not worth it. They’re on pill counts now and he has a mortgage to pay, he can’t lose his license.

  7. Since when have government officials ever given a fuck about the suffering they cause?

    Yet another reason I don’t want them completely in charge of health care. They cause too much agony as it is.

  8. The intelligent thing to do is to end all drug prohibition. Which is why it will never happen. Prostitution as well.

    1. The intelligent thing to do is to end all drug prohibition.

      At least take a good whack at hyper-credentialism. If I tell the doctor I’m in pain and need more painkillers, his oath (to the government? the licensing board? his med school?) shouldn’t be the final word.

    2. theres too much money in prohibition, the government makes far more than those who supply illegally.

  9. So people have to suffer in pain because a suggestion was mistaken as a requirement???!!!

    1. I’d bet not following that suggestion in some states would lead directly to a license revocation.

      1. “I’d bet not following that suggestion in some states would lead directly to a license revocation.”

        Sort of what happens when you ignore the ‘suggestion’ to pay your taxes.

    2. It worked for Title IX.

  10. I had a major burn on my arm last year, finger tips to biceps. Local hospital gave me morphine, ambulance to burn center (1.5 hours away) gave me fentanyl, burn center said, “only 2nd degree burns” and gave me Tylenol 3 and sent me home. I was in the worst pain in my life and got very ineffective meds. Happened on a Friday, went to my doc on Monday and he gave me… Tylenol 3! WTF!

    Finally found some hydrocodone 7.5 in my medicine cabinet from a surgery 12 years ago. It was life saving medication, I was considering suck starting a shotgun.

    1. Hey, we’re trying to prevent overdoses here. If that means someone in legitimate pain is driven to their death, that’s just the sacrifice that has to be made.

      It’s as if Blackwolf was running things.

    2. Burn pains last far longer than most pain and these doctors know it but I guess they are like the rest of america scared of our government instead of our government scared of us

      1. After about two weeks I was mostly pain free. I’m a nice guy, but I told my doctor if I was ever in that kind of pain again and he didn’t treat it seriously I would kick his ass and find a new doctor. His little Indian eyes got real big, I just narrowed mine – I was dead serious. I really like him as a doctor, he keeps on top of my many medical issues and I’d hate to lose him, I’ve been going to him since 2006 and we never had a problem before, and I don’t believe we will have one again. He knows my pain tolerance, and he knows I have been on opioids with successful results and no addiction issues, so now he also knows if I need I will ask and he better help. I hope I don’t have to find out.

    3. That’s bizarre. Mrs. Casual had her gall bladder removed recently. When admitted for the pain, they ran an IV and said they were going to give her something to ease it. She’s always been a lightweight and in less than 10 min. she was unconscious and her pulse O2 was steadily decreasing. They put her on oxygen to stabilize her O2 and monitored her breathing. I asked what they put her on and they said fentanyl. When I mentioned that they don’t mess around and that I expected them to start off with Tylenol 3 or something, they said they don’t even have it in the building. It’s only effective in some patients, isn’t any better than OTC options when it does work, and can cause stomach upset.

      1. Had a kidney removed in 2007 which is when I got the hydros 7.5, I was in the hospital for a week and don’t remember much of it, my wife had to tell me how long I was there.

        For the burn the local hospital gave me morphine in an IV, and the sweet, sweet lady in the ambulance gave me fentanyl twice, once when we left, and again about 5 minutes before we got to the burn center. I used the ride to monitor my own vitals and calmed everything down. I guess the burn center though I was handling the pain okay and wrote a script for Tylenol 3 and sent me on my way. I was in agony before I made it home and was going in and out of shock that evening. Should have taken the burn center up on their offer to stay if I wanted to. The worst pain, by far, was the wound care place. I took a hydro before going in and it wasn’t enough, toughed it out and they did a good job, but goddamn, that hurt. Close second was home bandage changes, I literally screamed the first time due to no hydros, I quickly found them after that.

  11. All drugs should be over-the-counter, at least for adults. But that doesn’t mean there wouldn’t be more deaths from overdoses with legalization.

    I know two people on opioids, and each keeps needing more of them. Neither has the will to endure the pain/nausea of withdrawal. One (in England) has the resources for a long term program and may get it when he has time. The other does not have the resources for such a program and would likely go back to opioids even if he ‘recovered’. He will likely die of an overdose, probably within 10 years.

    With legalization, things like this will eventually stop as people learn.

    1. With legalization, things like this will eventually stop as people learn.

      I think this is a key aspect that gets overlooked. For decades, everything was “as addictive as smoking” or “as addictive as cigarettes”. Then, once people started quitting smoking, everything became “as addictive as cocaine” or “as addictive as heroin”. To the point that some people have even said sugar is as addictive as heroin. I don’t doubt that it’s hard to stop taking heroin or opiates once addicted but I think a big part of the reason it is hard to quit is because of the legal stigmatization. Sugar is more addictive, but most people can give up sugar at the drop of a hat and without withdrawal. The “problem” there is culturally induced relapses. With drugs being illegal, it becomes difficult to figure out what activities contribute to addiction and quitting because the legality precludes so many activities.

      1. Completely forgetting to circle back to my original point, now that vaping is a thing and people have by-and-large learned how to avoid smoking, there’s evidence that nicotine isn’t exactly much worse for you than caffeine and that absent inhaling combustion products smoking isn’t/wasn’t much worse for you than coffee.

      2. Nicotine by far remains the “last addiction.” But the increased social stigma has had a major impact on people’s ability to quit.

  12. I find it amazing that the CDC can support government prohibition of informed adults use of opioids, which have probably killed hundreds of thousands in the last century, but are fine with even school children being exposed to socialist politics, which have definitely killed hundreds of millions.

    CDC memorandum from 1997: Lack of Loyalty to State Linked to Outbreak of Starvation in North Korea

    1. Wow. You need to get off the internets and get a girlfriend man. Maybe go fishing or hunting (for game, not socialists). Enjoy a sunset or a day at the beach.

    2. Any government department that has Control in it’s name is going to support some sort of government prohibitions.

      It’s like we’ve been hearing these words for so long we don’t recognize what they actually entail.

  13. Opioid pain killers serve an effective purpose in pain management, especially for debilitating and chronic pain that would otherwise render a person bed-ridden (think degenerative disks in the spine). Personally, I’d rather be addicted to pain killers and be able to go to work, than not addicted and unemployed.

    1. ^THIS^^

    2. And people like that were never really the problem.

      The real problem is that doctors have never been any good at sorting those sorts of people from all the others sorts (some of which are a major source of the actual problems.)

      Government thinks that adding more rules into the mix is somehow going to make them better at what they were never good at to begin with.

      Department of Wishful Thinking and Good Intentions (ie. Benevolent Tyranny)

  14. An MD spends 5 years I think studying after a bachelor at the cost of a quarter million dollars if everything goes well and he’s not even given the competence to decide what fits his/her patients best. I don’t understand why they accept that.

  15. Don’t believe mainstream media that 90k die annually, it’s more

  16. Stay at home mom Kelly Richards from New York after resigning from her full time job managed to average from $6000-$8000 a month from freelancing at home… This is how she done it

    ???????????? http://www.Net440.com

  17. I hope people have at least read the letter and the CDC guidlines.

    They are easily found here.

    The CDC is not a lawmaking body. The guidlines should mean no more than those written by other medical organizations. Suggestions to help guide practice.

    Yet often these become standard of practice. In opiate prescribing that can become law adopted by state medical boards or even if worded ambiguously become adopted in practice by doctors who fear legal action, and for good reason.

    What this rather small group is asking for is more specific wording. This has become very political and medicine is losing control.

    Well I wish them well, it should not. The CDC should probably not have been involved at all. It has been a valuable resource in epidemiology and fighting infectious disease. Let it limit itself to informing doctors about where the flu is or mortality rates for deaths from other causes.

  18. if you’re truly in chronic long term high level pain, go to Mexico for the pills. This fucking US govt would rather see thousands of people suicide a year over chronic pain than let one fucking junkie OD.

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