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AMA Decries the Impact of the CDC's Opioid Guidelines on Pain Treatment

The physician group says widespread "misapplication" of the guidelines is hurting patients.

AMAAMALast 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."

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  • Hugh Akston||

    The guidelines were supposedly optional and advisory,

    Y'know, Like all government standards.

  • DASGUY||

    It is such BS. The doctors are afraid of being charged with criminal activity. My RX is now closely monitored by everyone.

  • dan'o en barrel||

    Yep. My wife has been in hell for the past 9 months during her "voluntary titrate" to get in line with the 90 mg MME by 2019 (her dose has been more than halved.) She's 33 and now only out of bed for an hour or two each day.

    Is there anything more dangerous than when "DO SOMETHING" hysteria is bipartisan?

  • ThomasD||

    This article is sloppy, lazy, and incomplete.

    The Guidelines were advisory until state boards of pharmacy started incorporating them in practice standards, and insurance companies decided they would be an easy way to decline coverage.

    Dollars to donuts that is what actually happened in the mentioned case. The pharmacist didn't 'contact's the insurance. He submitted a claim for coverage/payment and the insurance denied it.

    It's still a horrible mess for people who need or want these drugs, but oversimplified stories and self serving announcements from the profession that claimed ultimate AUTHORITY over these substances is not going to solve anything.

    The AMA would be better served if every pronouncement they ever make included an explicit statement that they only apply to professional members and NOBODY else.

    But that's not how they roll.

  • Pastor Arthur M. Kirkland||

    I'm very much pro-opioid. So long as they're being consumed by the Trump-worshiping, beer-swilling, plaid-wearing hillbillies who are turning this country into Nazi Germany, they should be readily available in deplorable country.

    The 65.8 million of us who are on the right side of history will never forget the evil they're responsible for.

  • Don't look at me!||

    If you think this is anything like nazi germany, you have exposed your total and complete ignorance of history and world affairs.

  • Pastor Arthur M. Kirkland||

    You're shielded by a thick cocoon of hatred, white privilege, and Faux News propaganda. Imagine how people of color feel without a Democrat in the White House to protect them.

  • Pastor Arthur M. Kirkland||

    I'll let someone brilliant like Kirsten Powers explain.

  • Mongo||

    Nazi Germany was into Pervitin.

    Opioids mellow you out.

  • Dillinger||

    list of things I'll let Kirsten Powers do does not include "explain".

  • PavePusher||

    What drugs are YOU currently under the influence of? Because your only other excuse is abject fucktardery....

  • croaker||

    You may as well use Occasional-Cortex as your spokes droid.

  • DASGUY||

    You do have the talking points down. Good for you.

  • jdgalt1||

    ROFL! If white privilege existed, Obama (who was 50-50, remember) would have identified as white to benefit from it.

  • BigT||

    You're no OBL. But keep trying.

  • AlmightyJB||

    I don't know, that was pretty good. OBL needs to keep his game up.

  • ipsquire||

    Dr. AMA Lady says "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."

    She knows him well enough to know he's "very proud" but not well enough that he'd call her office to say your prescription was outside normal practice. Ok. Maybe she should use the Bluetooth in her Mercedes to call at-risk patients on her way home to the posh suburbs?

  • Hugh Akston||

    Maybe she's not as good a doctor as you are.

  • ipsquire||

    I'm sure she's a fine doctor, she just needs to stop blaming others for her lucrative shortcomings.

  • Fuck you, Shikha (Nunya)||

    Are you fucking serious? GTFOH.

  • ThomasD||

    Having made a professional judgement that a patient needs/warrants a particular course of treatment (that's what writing a prescription means) it is your professional responsibility to follow through and see that the patient receives it, or if there are problems, address them and/or devise an alternative course of treatment.

    That's the standard the doctor has chosen to abide and uphold; pointing fingers at insurance, or pharmacists, or government regulations then washing your hands of the matter is not.

    Physicians, as exemplified by the AMA, have made a Faustian bargain. They claimed ultimate authority over the prescription of drugs. Yes they have ceded a little ground to mid level practitioners, but they still claim to be the ultimate arbiters. Yet they refuse to accept that that 'prize' came with tremendous strings attached. They chose to place themselves between the public and unfettered access to drugs.

    That they remain in denial about the very real obligations this imposes on their profession is unsurprising, but also a great disservice to the 'patients' they claim to be oh so concerned about.

  • Daniel||

    CDC: These are recommendations only.

    Legislators look to CDC recommendations: If the CDC recommends it, we should make it a law.

    Doctors: WTF?!

  • RoyMo||

    Unless a doctor is an immunologist they wouldn't be working at the CDC if they were actually interested in helping patients as individuals.

  • John||

    Am I the only one who thinks the doctor is kind of hot?

  • Ron||

    Yes your alone

  • John||

    I bet Crusty would agree with me.

  • Fuck you, Shikha (Nunya)||

    Does he like bird women?

  • jello.beyonce||

    Because the only ones whom can fuck up public policy better and faster than bureaucrats and politicians are "FREE MARKET" PRIVATE special interest groups.

    It was the complete ineffectiveness and failures of the AMA, and lack of personal self-restraint by medical personnel, that led to the screwed up bureaucratically administered Medicare system in the first place.

    Medical industry "professionals" are just trained monkeys, taught merely to push high-cost drugs and procedures, to make up for any potential lost profits in the pharmaceutical and insurance industries.

    They all work solely to enrich the .001 percent.

    Often, those calling most adamantly for "Free Markets" are those most ignorant of mistakes of the past, and with the least skills for efficient and effective change.

  • John||

    Look Hihn just because modern medicine can't yet treat the kind of insanity that you suffer from doesn't mean that it isn't valuable. or that medical professionals don't do great things. You are a hopeless case. That is no one's fault but your own.

  • BYODB||


    Often, those calling most adamantly for "Free Markets" are those most ignorant of mistakes of the past, and with the least skills for efficient and effective change.


    Wrong. No worries though, you sound like you're just crazy enough to believe what you say.

  • Sevo||

    jello.beyonce|11.19.18 @ 1:47PM|#
    "Often, those calling most adamantly for "Free Markets" are those most ignorant of mistakes of the past, and with the least skills for efficient and effective change."

    It is amazing how often we get low-watt-bulb adolescents (or very good impersonators) to who up and explain that those of us who have researched the issues for years missed this one really important fact ("#10 will amaze you!").
    Fuck off, idiot.

  • BYODB||

    What would I know, I've only worked in healthcare for 15+ years.

  • JFree||

    I don't know whether CDC in this case is actually going beyond its actual knowledge/experience re public health and epidemiology - but I'm quite certain that AMA is nothing but the usual doctor lobby group looking for free money via public spending decisions.

  • Qsl||

    Typically, even doctors are behind the curve in the best practices for safe opioid administration, unless they work hospice or something equivalent. Granted the AMA already screwed the pooch with monitoring patients on opioids, inviting oversight from the legislature.

    And even the pharmacist is probably staring down criminal charges for deviating from CDC guidelines regardless of medical necessity, which is damn effective in reorienting, even if it is subconsciously, how they view pain management, .

    The whole thing is a mess, and probably going to get worse as I foresee a new round of congressional hearings to address the liver damage and deaths caused by the new guidelines.

  • Sevo||

    "The whole thing is a mess, and probably going to get worse as I foresee a new round of congressional hearings to address the liver damage and deaths caused by the new guidelines."

    Some congress-critters with long-term, painful illnesses might help also. Sorry to wish that on anyone, but *they* are going far beyond "wishing" it on the rest of us.

  • loveconstitution1789||

    These fucking crony doctors caving to political pressure.

    End the unconstitutional Controlled Substances Act.

  • Longtobefree||

    Maybe Doctors should start legislating for as long as legislators are doctoring?
    Setting specific limits on any drug is just nuts, which is why politicians love it. Saying everyone, from a 98 pound, 90 year old woman recovering from surgery to a 275 pound, 35 year old worker with a permanent disability should receive the same prescription amounts of a medication is like saying teenagers are capable of understanding the physical and emotional consequences of killing a baby. No sane legislator would say that, would they?

  • Sevo||

    Longtobefree|11.19.18 @ 2:53PM|#
    "Maybe Doctors should start legislating for as long as legislators are doctoring?"

    Please no.
    Some self-righteous MD in SF has a tweet which has now 'gone viral' (several hundred of equally obnoxious people agree). She is claiming MDs should be the people who decide on 'common sense' gun laws.
    Maybe doctor should STFU and stick to curing people.

  • Sevo||

    BTW, whoever the woman is in the image needs to find something smaller than a 4" brush to do her eyebrows.

  • Fuck you, Shikha (Nunya)||

    Careful, John will take umbrage with you. He's apparently got and bothered with this chick.

  • Uncle Jay||

    No one should be given pain medication.
    Suffering and pain is nature's way of telling you something is wrong with your body.
    A real adult would just rip open their body with a chain saw and take care of the problem instead taking all those sissy drugs to alleviate all pain instead of welcoming it.
    We've become a nation of sissies.

  • Sevo||

    UJ, I got an overstock on hair shirts. Can I interest you in some inventory?
    (got the sarc)

  • AlmightyJB||

    If God didn't want you to suffer he would take away your pain.

  • ozzy||

    100 people a day are not dying from prescriptions for pain relief. If I had to guess few die every year from legitimate prescription the rest that die are either addicted and switch to illegal MS13 pain relief or point blank idiots trying to get high rather than pain relief again most are from MS13 heroin not Bayer Heroin.

    Meanwhile people in pain will suffer and our representatives do not care.

    It really is time to legalize everything and let people do what they want.

  • AlmightyJB||

    Truth

  • jdgalt1||

    In this case, gradualism is ruining lives. We should demand that opioids be made available OTC immediately.

  • Alizen||

    As a chronic pain patient, I can testify to the insanity of these knee-jerk reactions. When I started having the VA manage my chronic pain two years ago, my pain meds were cut by 80% b/c of CDC guidelines. I went through 4 months of agony & was very suicidal. There was no titration to the abysmally low dose. I'd been on opiates for 14 years & had an extremely high tolerance. I have never abused my meds.
    The VA here has no pain clinic, so PCMs manage all chronic pain patients. A task they are not qualified or interested in doing.
    Now my state has passed a law that opiate patients must see their doctor every month for refills. The VA is mandated to comply with state law. The problem is, the VA PCMs are understaffed, there aren't enough slots for this new caseload. Patients won't get their meds on time & the likelihood of drug withdrawals & escalating pain/suicide rates is great. I was told to go to the ER for my refills. That over taxes a critical department. Not to mention my inconvenience & wasted time.
    Also, I recently qualified for medicinal Cannabis. It's an effective adjunctive therapy for me. But, my VA PCM refuses to prescribe any pain meds if I test positive for THC. I'm legal, but I'm not legal too. Hanging out in Limbo Land sucks.
    The whole system is broken & is causing needless suffering. Legislation on all this needs a strong dose of common sense.
    I'm glad doctors are protesting these draconian, ill-fated measures.

  • Fuck you, Shikha (Nunya)||

    The unfortunate piece I take from your even more unfortunate experience is what I believe law makers will hear. Their prescription will be to make suicide even more illegal if attempted. Most likely starting with firearm confiscation, later to confiscate firearms as soon as opioids are prescribed.

  • ThomasD||

    The VA is not mandated to comply with state law. They are on Federal land and are not legally bound by any state.

    They choose to comply for a bunch of reasons, but it's more about convenience.

  • Observant||

    I've been on opioids for years now, helping with pain still felt after a deer-broadsides-car incident. Walmart Pharmacy refused to fill my opioid Rxes a few months ago after the latest 'guidelines' were posted. I argued with the pharmacist, who had no choice but to comply with his company's new policy. I told management they had no medical license to circumvent my physician's protocol for me. They didn't care. I had to switch pharmacies, and the one I now use for the opioids is not on my Part D's preferred list, so I have to pay more for the same drugs. The Controlled Substances Act needs to be totally eliminated because it's just an excuse for the government being my doctor - again without a medical license to prescribe anything, and absolutely no working knowledge of my health history. How dare they nanny me, a 70 year-old mentally competent adult? I'm 'grateful' I can still get what I need, but I don't know how long that will last either. Fuck them all: government & pharma lobbyists. They have no interest at all in a patient's health and well-being.

  • ThomasD||

    All pharmacies that stock controlled substances must have a DEA license. DEA regs impose a "corresponding duty" on the pharmacists to comply with all applicable laws,regs, and professional standards. Some states also require a controlled substance license/permit beyond the standard professional licensure that creates additional burdens.

    If course, most states allow prescribed to dispense. So it is quite likely you and your doc could avoid the second guessing middlemen, but he probably doesn't want to deal with the added work and low rate of return on his time and space. Or the added liability.

    You could try contacting your D plan and see if something can be worked out. Or change your plan. Your new pharmacy might even help you find the right plan.

  • ThomasD||

    All pharmacies that stock controlled substances must have a DEA license. DEA regs impose a "corresponding duty" on the pharmacists to comply with all applicable laws,regs, and professional standards. Some states also require a controlled substance license/permit beyond the standard professional licensure that creates additional burdens.

    If course, most states allow prescribed to dispense. So it is quite likely you and your doc could avoid the second guessing middlemen, but he probably doesn't want to deal with the added work and low rate of return on his time and space. Or the added liability.

    You could try contacting your D plan and see if something can be worked out. Or change your plan. Your new pharmacy might even help you find the right plan.

  • ellaandscruc||

    I won't let insurance co. dictate whether I'm in pain...I would have gone ahead and paid for the gentleman's morphine and then try to re_coup the cost. morphine is surprisingly not expensive. been around too long

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