On March 15, 2016, the Centers for Disease Control and Prevention (CDC) published its Guideline for Prescribing Opioids for Chronic Pain. The recommendations were designed for primary care clinicians who are prescribing opioids for chronic noncancer pain. Its purpose was to lower the supply of prescription drugs and decrease the number of opioid overdoses.
Pain advocacy groups were concerned that the CDC Guideline for Prescribing Opioids for Chronic Pain could have unintended negative consequences when they were introduced. For example, the Cancer Action Network‘s president, Chris Hansen, published a statement called “Final CDC Opioid Prescribing Guideline Could Have Unintended Consequences for Cancer Survivors Living with Chronic Pain.” It read, in part, “We are disappointed that the CDC guideline released today did not address our previously stated concern about needed access to opioid analgesics for cancer survivors who experience severe pain that limits their quality of life.”
{mosads}The CDC positioned the guideline as voluntary. But, five months after the guideline was published, the CDC was cautioned by a public relations firm they hired, “Some doctors are following these guidelines as strict law rather than recommendation, and these physicians have completely stopped prescribing opioids.” The CDC ignored the warning.
Even worse, last month, the Oregon Health Authority proposed denying access to opioids for most people with chronic non-cancer pain. The Oregon Health Authority has lost sight of the fact that the amount of opioids prescribed is only one factor — and may not be the primary factor — contributing to the opioid crisis. Lack of access to adequate mental health and addiction treatment has also contributed to the problem.
Oregon is not the only state that is limiting access to opioids. Michigan, Florida, and Tennessee are among other states that have also passed laws restricting physicians’ ability to prescribe opioids. Utah-based Intermountain Healthcare has implemented forced tapering to achieve their goals of lowering prescriptions by 40 percent in 2018. In other states, health-care plans and insurers, such as Cigna and Aetna, have similar goals.
The assumption that denying prescription opioids to those in severe pain regardless of the diagnosis will stop abuse is foolhardy and harmful. As states and insurance companies begin to implement similar restrictive prescribing policies for the treatment of chronic pain, we will see at least two negative effects:
First, people with a substance abuse disorder (SUD) who are using prescribed opioids for the wrong reasons are not going to suddenly stop using drugs because they aren’t readily available. Instead, they will seek other sources of drugs. They will turn to the streets for their opioid replacements. This may contribute to more deaths, because the streets are where the most dangerous drugs are found.
This is illustrated by what occurred when the abuse-deterrent OxyContin was introduced. Abusers began substituting heroin when OxyContin became more difficult to obtain and abuse. The National Bureau of Economic Research’s published 2017 report, “Supply-side Drug Policy in the Presence of Substitutes: Evidence from the Introduction of Abuse-Deterrent Opioids,” explains how supply-side strategies alone are inadequate for dealing with drug abuse.
Second, people in pain who have been functioning on their medication without signs of abuse may be at an increased risk for suicide. Without adequate pain treatment, they may lose significant quality of life. In some instances, people will feel abandoned and hopeless.
It is not an exaggeration to suggest that some people in severe pain who are denied access to opioids will view suicide as the only way to escape their severe pain. Inadequately treated pain is a risk factor for overdoses and suicides. Recent research suggests as many as 30 percent of unintentional opioid-related overdose deaths may be suicides.
Certainly, opioid abuse is a significant problem and must be addressed. But policies to force opioid tapering as a way to mitigate the opioid crisis are ill-conceived. To set arbitrary dose limits without consideration of patients’ needs is malevolent.
The CDC needs to respond to the unintended harm the guideline has created. They should follow the lead of Canadian physicians. The College of Physicians and Surgeons of British Columbia (CPSBC) revised the guidelines that they adopted from the CDC following consultation with physicians in the Province and patients who were being denied care, abandoned, or forced to decrease doses to 90 mg morphine milligram equivalents (MME) or less suggested by the CDC guideline.
By contrast with the CDC, the CPSBC recognized the harm that the guidelines were producing for some patients, and they had the courage and leadership to clarify their previous recommendations. They announced, “Physicians cannot exclude or dismiss patients from their practice because they have used or are currently using opioids. It’s really a violation of the human rights code and it’s certainly discrimination and that’s not acceptable or ethical practice.”
The nonprofit New York-based Human Rights Watch (HRW) organization that typically tracks and exposes war crimes apparently agrees with the CPSBC, because they recently expressed concern about the CDC guidelines’ potential consequences for pain patients. HRW is investigating whether people’s right to receive appropriate health care when they are in pain has been violated if they have been forced to reduce their medication. They expect to produce a report later this year.
It is important to find answers to the drug crisis, but the solutions must not create more harm than benefit to both people in pain and people with addictions. The current implementation of the CDC’s Guideline for Prescribing Opioids for chronic pain does not achieve this end and is not patient-centered. Hopefully, the CDC will assume the responsibility to clearly state their guideline is not being implemented as they intended.
The CDC should issue a public statement similar to the one published by the CPSBC clarifying that physicians should not dismiss patients or deny them access to pain care because they are on opioids, even if the dose they need is above 90 mg MME. This is not advocating for opioids but, rather, advocating for patients. It respects the human right to receive compassionate care.
Lynn R. Webster, MD is a vice president of scientific affairs for PRA Health Sciences and consults with Pharma. He is a former president of the American Academy of Pain Medicine. Webster is the author of “The Painful Truth: What Chronic Pain Is Really Like and Why It Matters to Each of Us.” You can find him on Twitter: @LynnRWebsterMD.