“I hope I live until 2023 to see changes in pain control,” a woman I’ll call Nancy H said in a recent email. “I have been treated with opioids for over 25 years at a world-renowned hospital pain management center in Boston. I now suffer daily because I was reduced from 150 mg of OxyContin and 60 mg of Oxycodone per day… to only 60 mg of Oxycodone.”
As a health care writer and advocate for people living with chronic pain, I get a lot of messages like this. They reflect the experience of patients suffering the consequences Opioid prescribing guidelines which the Centers for Disease Control and Prevention (CDC) published in 2016. sharp decline in medicine, under treatment of pain, Reduced access to careand direct abandonment of patients, as a result Unnecessary suffering And sometimes suicide.
The alarming results from the CDC’s 2016 recommendations, which inspired laws, regulations, policies and practices aimed at reducing medical use of opioids, were clear to patients. Pain specialistsAnd American Medical Association. Draw attention from it Food and Drug Administration And finally urges the CDC the problem New, supposedly improved guidelines in 2022.
The revised version The CDC implicitly acknowledges the harm caused by what it describes as the “misapplication” of its advice. But the agency’s updated recommendations maintain a bias against treating pain with opioids and a preoccupation with arbitrary dose limits. They do little to address doctors’ fears of regulatory or criminal sanctions, and they do nothing to reverse the confusing rules that lawmakers, regulators, insurers, pharmacists and healthcare organizations adopted in response to the 2016 guidelines. A true course correction will require new legislation, which starts with recognizing how harm has been done to patients like Nancy H.
“total madness”
“The pain and other withdrawal symptoms from this forced taper are horrible, and the pain I suffer is unbearable,” wrote Nancy H. “My pain management physician didn’t want me and other patients to decrease from our prescribed amount. The hospital board mandated that all patients being treated for non-cancer pain be reduced to 60 mg. My physician and other physicians at the pain clinic were told that if they Every patient not reduced to 60 mg will be dismissed.”
According to scientifically questionable conversion system Used by CDC, the daily dose of oxycodone is 90 “morphine milligram equivalents” (MME), a threshold that 2016 guidelines warned doctors against crossing. The 2022 guidelines drop that recommendation but include a warning that is potentially more damaging.
“Before increasing the total opioid dose to ≥50 MME/day, the CDC states, “Clinicians should pause, considering that increasing the dose to 50 MME/day is unlikely to provide significantly improved pain control for most patients while the risk of overdose increases with dose, and careful consideration of benefits.” and reassess the risk evidence.” Although this dire suggestion implies that daily doses exceeding 50 MME are rarely appropriate, mThere have been millions of patients Well served by opioid therapy At much higher doses, often for years without negative results.
The 2016 guidelines did not say that patients who already exceeded the 90-MME threshold should be forced to go lower. But that’s how the guidelines have been widely interpreted, as illustrated by Nancy H.’s account, which like many others. Report On social media. “With so many chronic pain patients,” he says, “I’ve given up any hope that I’ll ever get the pain management treatment I need to have some quality of life.”
The 2016 guidelines, like the revised version released last year, were not supposed to affect cancer patients or end-of-life care. But they contributed to an anti-opioid culture that led to the horrific mistreatment of patients on their deathbeds.
“My husband, who recently died of brain cancer, spent many of his final days in agony,” Rhonda F. reported in an email dated January 2023 “I had to fight for him to get any pain relief. Yes, a wonderful man with terminal brain cancer suffered. I asked the doctor why no one was giving Larry pain relief, and he replied, ‘They’re all afraid for them.’ license.’ My poor, dead husband would cry, put his hands over his head and cry, it’s complete and utter madness.”
One size does not fit all
The frenzy began with the belief that pain relievers prescribed by doctors — even for bona fide patients — caused and perpetuated the “opioid crisis.” But the CDC cited in its 2016 guidelines the correlation between opioid prescribing and drug-related deaths. No longer visible After 2010. The 2022 amendments nevertheless falsely rely on the same connection old number To support the belief that reducing prescriptions will somehow reduce opioid-related deaths, which are widely implicated these days Illicit Fentanyl.
Meanwhile, at least 40 percent of US community clinics refusing to accept New patients for pain management. Many pain patients are dropped by their doctor Can’t find anyone to continue to care for them.
The 2022 guidelines state that nonpioid therapies are “preferred” for most patients. But the medical literature doesn’t support that recommendation, especially for acute pain. No published trials Compare opioid therapy with non-pharmacological treatment on an either-or basis. When pain relief supplements are used, alternative treatments such as acupuncture, physical therapy, and counseling Offers only marginal and temporary improvement in pain or quality of life. Although prescription opioid therapy is not a default first option for all patients, it is essential for both acute and chronic severe pain when alternatives are less effective.
Like the 2016 guidelines, the new version completely ignores genetic variations in drug sensitivity among individuals. Because of these differences, which have been recognized for at least 20 years, the minimum effective dose is estimated to be as much as 15 times more For some patients more than others with similar conditions. But published medical trials do not address this wide variability, and neither do the CDC’s one-size-fits-all practice standards.
CDC said Its guidelines “should not be applied as an inflexible standard of care across patient populations.” But the CDC’s bias against opioid therapy in general and high-dose therapy in particular, which is a Exaggerated depiction It negates the risk it entails.
It is clear that we cannot rely on the CDC to correct its errors. But state and federal policymakers can take steps to reduce the harm caused by ham-handed efforts to reduce medical use of opioids.
What legislators can do
Physicians need an evidence-based practice standard for prescribing opioid analgesics, and they need to be confident that following this standard will protect them from criminal prosecution, regulatory sanctions, and institutional punishment. Such guidelines shall necessarily replacement The CDC recommends, and may require, federal law to prevent the agency from telling doctors how to practice medicine.
There are six medical institutions in the United States call for “Ending Political Interference in the Delivery of Evidence-Based Medicine.” These organizations represent more than 500,000 frontline physicians and medical students spanning family practice, internal medicine, obstetrics/gynecology, osteopathic medicine, pediatrics and psychiatry. Additional specialties are represented by the American Medical Association Substance Use and Pain Care Task Forcewhich aims to “promote evidence-based policies to end the epidemic of drug overdose deaths.”
A truly balanced practice guideline could be developed by a committee of clinicians who actually practice pain management in the community or hospital, with representation from clinical specialty academies and organizations. like Inter-Agency Task Force on Best Practices in Pain Management As the US Department of Health and Human Services established in 2019, such committees should include chronic pain patients and their advocates as voting members.
The work of the committee should be started with a few basic policy. Treatment begins with a collaborative, face-to-face relationship between patient and physician. This includes documenting therapy plans, monitoring progress, tailoring treatment to the individual, and educating patients and family caregivers. Clinicians and patients should understand the difference between addiction—a compulsive attachment that persists despite identifiable harm—and physical dependence, which includes withdrawal symptoms after sudden cessation. Physicians must also recognize that forcefully shortening stable patients is never ethically appropriate and Patients’ lives may be at risk.
Pending completion of that project, Congress should ask the CDC to withdraw its pain treatment recommendations and notify state medical boards that they will not rely on those guidelines in regulations or standards of practice. Congress should also repeal Sections 131 and 133 of 2018 Veterans Affairs Mission Actwhose goal Reduce opioid prescribing The 2016 CDC guidelines are based on the same incorrect premises throughout the VA system. It should direct the VA to withdraw Opioid Safety Initiative and Clinical Practice Guidelines connected With this, which is used to justify Deny the blanket Opioid therapy for the elderly.
The Controlled Substances ActWhich the Drug Enforcement Administration (DEA) has for a long time deployment Against physicians whose prescriptions are deemed medically inappropriate, is another barrier to pain treatment. In last year Rouen v. United StatesThe Supreme Court may have mitigated that threat rule Doctors can only be convicted of drug trafficking if they “knowingly or intentionally” violate accepted standards for the medical use of controlled substances.
Amending the Controlled Substances Act could provide more protections for physicians who worry that their good-faith prescribing decisions could jeopardize their independence, licensure, and livelihood. Clinical staff should no longer be coerced by DEA agents who threaten prosecution to obtain testimony against physicians. Congress should also reduce pretrials Confiscation of assetsThat often denies physicians the resources they need to effectively defend themselves in court.
Several states including New Hampshire, Rhode Island, Oklahoma, ArizonaAnd Minnesota, has already enacted reforms aimed at protecting physicians from improper sanctions These laws are designed to prevent medical boards and law enforcement agencies from penalizing or prosecuting physicians for “appropriately” prescribing opioids within a “current standard of care.” No one needs to look to the CDC for that standard.
Emails quoted in this article have been edited with the author’s permission.