How many innocent lives must be harmed before the Centers for Disease Control and Prevention changes course on prescription opioids? The CDC recently released opioid guidelines, a recommendation for physician prescribing practices, and an update to the original 2016 document, which wrongheadedly attempted – and failed – to solve the opioid crisis by preventing physicians from prescribing pain medication to patients.
Six years later, with millions harmed, the CDC emphasizes that its guidelines should never be used for an “inflexible, rigid standard of care” and “patient abandonment.” However, if you read the fine print, that is precisely what I see the CDC advocating for.
The original guidelines came about from a lethal combination of bureaucratic arrogance and do-goodery, with the organization foolishly trying to stop substance abuse by making prescribing more difficult and, thus, the drugs more challenging to acquire on the black market. According to the Journal of Pain Research, “Data suggest that the overdose crisis is largely an unintended consequence of drug prohibition.”
As a reporter and disabled pain patient, I have witnessed the heart-wrenching effects on abandoned patients and their loved ones when they are denied these essential medications just for the crime of getting sick. And, yes, contrary to whatever those on Capitol Hill or institutions like the Florida Department of Health have suggested, these medications are irreplaceable, a necessary element to making modern medicine possible.
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Drastic changes mean major consequences
Among these drastic changes was a limit for acute pain at three days and a new hard limitation at 90 “morphine milligram equivalents” (MME) for all prescriptions, substantiating an unscientific term not used by anyone but the CDC, which not only established an absurdly low dose for some patients but insinuated that the needs for pain treatment from patient to patient are the same regardless of individual metabolism and bodily chemistry.
Whatever the CDC’s intentions, the document was interpreted by 38 state legislatures, the federal government, law enforcement, Congress, every state medical board, hospitals and countries worldwide as a hard rule and clarion call for an open season on pain patients and their prescribers. Thus was born an opioid prohibition, as physicians understood they prescribed opioids at the risk of job loss and incarceration.
Studies and qualitative evidence overwhelmingly show that many – perhaps most – physicians now refuse to take on new patients who need opioid medication.
Potentially millions of patients have been abandoned when you consider that 1 in 5 Americans suffer from chronic pain, and in 2019 up to 8 million of them relied on opioids for long-term therapy.
It doesn’t stop at pain patients:
Law enforcement agencies, especially the Drug Enforcement Administration, are out of control, with the DEA routinely caught releasing “safety plans” for the patients of arrested physicians that simply direct pain patients to the nearest emergency room.
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If that sounds like a recipe for a horror show, it’s because it is. The impact felt by physicians is so severe that it forced the Supreme Court recently in Ruan v. United States to emphatically push back against law enforcement in favor of physician prescribing privileges.
So does this new guidance, with the CDC emphasizing the document as a tool to provide the “safest and most effective pain care possible,” hold up to its promise – as many have claimed in major publications like The Washington Post or NPR? Absolutely not.
Stringent ‘guidelines’ morph into mandates
While there are some positive tweaks, including warning physicians against using drug test failures as a reason for discharging patients and encouraging physicians looking to taper patients off opioids to go more slowly – though not more voluntarily – all of this is belied by an even more rigid regulatory framework.
The CDC here is two-faced. It wants critics to think it has zapped away the bad guidance recommending medically detrimental regulations, as in recommendation No. 4: “When opioids are initiated for opioid-naive patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.”
That sounds a positive change, right? Well, they don’t tell you upfront, but what’s crystal clear in the notes and tables of evidence is that there’s now an even more strict limitation at 50 MME, down from the previous 90. The 2022 CDC guidelines are more stringent on opioids than the 2016 guidelines – not less.
The whole document is like that: Write something nice about treating patients with kindness at the front, then tell regulators what the CDC really thinks at the back.
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Even more reasonable proposals are more dangerous than they first appear. The updated guidelines recommend the usage of prescription monitoring programs and divvying up the opioid overdose drug naloxone for all prescriptions. This sounds great in theory, but it also increases the potential legal liability for prescribers.
Additionally, the CDC covers new categories of pain coverage, not just acute and chronic, meaning more categories and more potential regulations.
Dr. Jeffrey Singer, a surgeon and researcher for the Cato Institute who has presented studies on opioid prohibition to Congress, agrees.
“The agency gives lip service to physician-patient autonomy by stressing that practitioners should view the revised guideline as recommendations, not mandates,” he told me in an interview. “Yet, as with any federal government agency guidelines, it is inevitable that the recommendations will morph into de facto mandates.”
Reading this report, I imagine many feel outraged. Nevertheless, while I share that anger, I do not share the surprise.
Kate Nicholson, the executive director of the National Pain Advocacy Center – who sat on the advisory workgroup for those same guidelines – told Pain News Network that for all these new slight positive changes in the guidelines, this “doesn’t mean it’s not still built on a rotten core.”
Yet as dark as the way appears for patients, there is hope. Ironically, the CDC is likely to find out that far from closing the book on the opioids question, the updated guidance will create even more suspicion among the public. Questions will multiply as stunned patients are dropped by their trusted physicians, and desperate family members demand an explanation for why their dying loved one cannot receive pain care.
Either the CDC changes course now, and patients’ lives are extended, or we wait a decade or two and a moral accounting is foisted up on them. Whatever the timeframe, change will come. I only pray that I and other patients live long enough to see it.
Peter Pischke is a disabled free lance journalist covering the opioid crisis, a contributor for Young Voices and host of the “CultureScape” podcast.
