Pain treatment

Two Senators With Business Degrees Want the FDA to Tell Doctors They Should Not Treat Chronic Pain With Opioids

The FDA Opioid Labeling Accuracy Act would aggravate the widespread problem of involuntary dose reductions and patient abandonment.


Sen. Joe Manchin (D-W.V.) has a bachelor's degree in business administration. Sen. Mike Braun (R-Ind.) has an MBA from Harvard. Yet the two senators seem to think they have the medical expertise to second-guess the judgment of physicians across the United States, not to mention the Food and Drug Administration. A bill they introduced last week, the FDA Opioid Labeling Accuracy Act, instructs the agency to tell prescribers that opioids are "not intended for the treatment of chronic pain."

Their reasoning is hard to follow. "In the United States," Manchin says, "we consume 80 percent of the world's opioid production and in 2017, one single year, over 70,000 people died due to drug overdoses."

The first figure largely reflects the fact that opioids remain appallingly unavailable in much of the world, even for purposes that Manchin and Braun would approve, such as "end-of-life care" and "treatment of pain related to cancer," both of which the bill mentions as exceptions. The second figure is highly misleading, since the category of opioids that includes the most commonly prescribed analgesics played a role in just one-fifth of those 70,000 drug-related deaths in 2017, according to the U.S. Centers for Disease Control and Prevention (CDC).

Furthermore, more than 90 percent of the cases that involved prescription analgesics such as hydrocodone and oxycodone also involved other drugs, most commonly illicit opioids such as heroin and fentanyl. Even if we focus on the relatively small share of drug-related deaths that involve opioid analgesics, blaming chronic pain treatment seems misplaced, since patients who depend upon these drugs to make their lives livable are not inclined to part with them, meaning that short-term prescriptions for acute pain are more likely sources of diverted pain pills.

Even while arguing that opioids are not appropriate for treatment of chronic pain in patients who do not have cancer and are not on the verge of death, Manchin and Braun concede that sometimes they are. Their bill makes an exception for cases where "a prescriber determin[es] that, with respect to a particular patient, other non-opioid pain management treatments are inadequate or inappropriate." Since that is the judgment doctors are already supposed to be making, the only point of this bill seems to be further discouraging such prescriptions by making physicians worry, even more than they already do, that their good-faith assessments of patients' needs will expose them to scrutiny that could deprive them of their licenses, livelihoods, and maybe even their liberty.

The government's crackdown on pain pills already has led to medically reckless dose reductions and patient abandonment across the country. The problem became so severe that the CDC recently warned that its 2016 opioid prescribing guidelines should not be interpreted as endorsing, let alone requiring, involuntary tapering or discontinuation, which may lead to "adverse psychological and physical outcomes" (including suicide), "could represent patient abandonment," and "can result in missed opportunities to provide potentially lifesaving information and treatment." A bill like Manchin and Braun's can only aggravate this problem, while making doctors less inclined to treat chronic pain to begin with.

"Most pain specialists agree that, in some cases, long-term opioid therapy is all that works for some chronic pain patients," notes Phoenix surgeon Jeffrey Singer, a senior fellow at the Cato Institute. "What the senators fail to recognize is that patients are not one-size-fits-all. Different patients respond to pain and to pain management differently. Their proposed legislation, if passed, will only serve to exacerbate the unnecessary suffering of patients in pain that the CDC is trying to undo with its guideline clarification."