No Shortcuts to Safer Opioid Prescribing | NEJM – Deborah Dowell, M.D., M.P.H., Tamara Haegerich, Ph.D., and Roger Chou, M.D. [!!!] – Apr 2019

This article is astonishing because Dr. Roger Chou has been one of the most influential anti-opioid crusaders. I’m thrilled that he’s finally understanding (or at least noticing) the problems (torture) caused by the CDC Guideline that he helped write.

Since the Centers for Disease Control and Prevention (CDC) released its Guideline for Prescribing Opioids for Chronic Pain in 2016, the medical and health policy communities have largely embraced its recommendations. Although outpatient opioid prescribing had been declining since 2012, accelerated decreases — including in high-risk prescribing — followed the guideline’s release.

“Accelerated decreases” is a deliberately innocuous term when referring to the brutal, suicide-inducing, drastic forced opioid tapers pain patients have had to endure.

Furthermore, the guideline was rated as high quality by the ECRI Guidelines Trust Scorecard.

Considering the sordid story of how this particular guideline was conceived and created by addiction specialists (and the purveyors of PROPaganda), this rating is just plain wrong.

In addition, the CDC (including the authors of this Perspective, who were also authors of the Guideline) engaged clinicians, health systems leaders, payers, and other decision makers [but no pain management experts! -zyp] in discussions of the guideline’s intent and provided clinical tools, including a mobile application and training, to facilitate appropriate implementation Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.

“Unfortunate” is not the right word when pain patients are yanked off the only pain relief they had, leaving many of them in literally unbearable pain:

Without opioid pain relief, their pain was so unbearable that they chose to die rather than continue living with it.

A consensus panel has highlighted these inconsistencies, which include inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice. The panel also noted the potential for misapplication of the recommendations to populations outside the scope of the guideline.

It seems disingenuous to call it “potential” when that’s exactly what *has* been happening. These days, even terminal cancer patients can’t always get their opioids and are forced to suffer a painful death:

I’m horrified at the lack of compassion from the people who create such situations.

Such misapplication has been reported for patients with pain associated with cancer, surgical procedures, or acute sickle cell crises. There have also been reports of misapplication of the guideline’s dosage thresholds to opioid agonists for treatment of opioid use disorder. Such actions are likely to result in harm to patients.

Here, at least, the “appliers” of the guideline are equal opportunity abusers: these punitive, unscientific, un-studied dose limits are being applied to both pain patients and people with addiction.

All of us who need prescribed opioids are now suffering under rules thought up by “experts” who never consult us or our “real world” situations. These ignorant publicity hounds are then endlessly quoted in the media. And just like the latest conspiracy theory, this misinformation spreads far and wide to anyone who has not experienced the “reality” of chronic pain themselves.

I’m embarrassed to admit that, before I was subject to it myself, I doubt I would have had much sympathy for people with chronic pain.

Before I was about 37, when I was still able to manage my own increasingly frequent and severe pain just by “powering through”, I thought these people were just weak for allowing pain to dominate them like it did.

It was only after finding myself backed into a painful corner by the failure of every other treatment that I accepted the idea that I’d have to take opioid medication indefinitely to preserve some quality of life.

We need better evidence in order to evaluate the benefits and harms of clinical decisions regarding opioid prescribing.

We also need better evidence that any of the touted “alternate” medicine treatments are effective.

In situations for which the evidence is limited, it is particularly important not to extend implementation beyond the guideline’s statements and intent.

It sounds like they are starting to backpedal a bit on their strict limits and deflect blame by claiming they never intended for the guideline to be used like it has been. I disagree: Were Consequences of CDC Guideline Unintended?

And yet in some cases, the guideline has been misimplemented in this way.

…and used as a bludgeon to force opioid tapers on chronic pain patients.

For example, the guideline states that “Clinicians should…avoid increasing dosage to ≥90 MME [morphine milligram equivalents]/day or carefully justify a decision to titrate dosage to ≥90 MME/day.”

…which should not be an issue with legacy patients because it addresses only “increasing dosage”, just as the guideline intended.

This statement does not address or suggest discontinuation of opioids already prescribed at higher dosages, yet it has been used to justify abruptly stopping opioid prescriptions or coverage.

After three long years of forced tapers, patient abandonment, and the resulting suicides, they finally noticed!

The CDC based the recommendation on evidence of dose-dependent harms of opioids and the lack of evidence that higher dosages confer long-term benefits for pain relief.

If there’s such a big problem because opioids lack “evidence” for long-term benefits, then how can they recommend “alternative” pain management methods that have even less evidence? (chiropractic, acupuncture, massage, aromatherapy, music therapy)

However, we know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them. Policies should allow clinicians to account for each patient’s unique circumstances in making clinical decisions.

That this actually has to be put in writing disturbs me because it implies that doctors nowadays practice *without* accounting for “each patient’s unique circumstances.”

Patients exposed to high dosages for years may need slower tapers (e.g., 10% per month, though the pace of tapering may be individualized). Success might require months to years. Though some situations, such as the aftermath of an overdose, may necessitate rapid tapers, the guideline does not support stopping opioid use abruptly.

Yet, that’s what many doctors did to patients – and in the name of the very guideline that tells them not to.

However, policies invoking the opioid-prescribing guideline that do not actually reflect its content and nuances can be used to justify actions contrary to the guideline’s intent.

Though the guideline says nothing about inflexible dose limits or tapering patients taking higher doses, politicians have seized upon the two numbers mentioned in the guideline, 50 and 90 MME, use as simple numerical limits of something they can control: opioid milligrams.

There’s no longer a need to use the subjective measurement of a patient’s pain to determine medication dosage. Pain care using opioids has been abstracted and removed from the realm of patient and pain care. Now, only the measure of the dose is needed to determine action.

This “unforeseeable” and “unintended” damage to pain patients has been going on for 3 long years, so I have to wonder why it took them so long to attempt a course correction.

Even guideline-concordant care can be challenging. Implementing recommendations with individual patients takes time and effort.

That’s called old-fashioned doctoring. The most successful practice of medicine is when a doctor is able to find and correct a health issue in the patient’s life.

Clinicians might universally stop prescribing opioids, even in situations in which the benefits might outweigh their risks.

Might? This was only a question before the guideline was released.

Since its release, there’s been a mass exodus of clinicians who, to avoid prosecution by the DEA and to preserve their careers and livelihoods, did “stop prescribing opioids”.

Such actions disregard messages emphasized in the guideline that clinicians should not dismiss patients from care, which can adversely affect patient safety, could represent patient abandonment, and can result in missed opportunities to provide potentially lifesaving information and treatment.

I’ve heard of multiple incidents of pain patients being abandoned by their doctors, if not specifically, then by insisting they go to a separate “pain management” doctor/clinic for their opioids… when those routinely have waiting lists of 6 months or more.

Isn’t requiring a patient to do the impossible — finding a new “pain doctor” and being prescribed opioids again before extreme crippling pain and/or withdrawal sets in — clearly a form of patient abandonment?

Effective implementation of the guideline requires recognition that there are no shortcuts to safer opioid prescribing (which includes assessment of benefits and risks, patient education, and risk mitigation) or to appropriate and safe reduction or discontinuation of opioid use. Starting fewer patients on opioid treatment and not escalating to high dosages in the first place will reduce the numbers of patients prescribed high dosages in the long term. Appropriate implementation of the guideline includes maximizing use of physical, psychological, and multimodal pain treatments

Why do they believe we haven’t done or aren’t already doing this?

However, these therapies have not been used, available, or reimbursed sufficiently Efforts to support more judicious opioid use will become more successful as effective nonopioid treatments are increasingly available and used.

Dream on… the closest candidate NKR- is still a couple of decades away from becoming available to patients.

The CDC is evaluating the (intended and unintended) impact of the guideline and other health system strategies on clinician and patient outcomes and is committed to updating recommendations when new evidence is available

I see zero evidence of this and haven’t heard about any research, studies, or surveys on outcomes. In fact, no one is counting the outcome: the level of pain that patients now have to live with, the hours they now spend bedridden, or the increasing numbers who find their untreated pain literally unbearable and thus end their lives.

The CDC counts every fatal drug overdose multiple times (once for each drug), yet refuses to count any suicides due to pain after forced tapers.

The CDC is funding the Agency for Healthcare Research and Quality to conduct systematic reviews on the effectiveness of opioid, nonopioid pharmacologic, and nonpharmacologic treatments for acute and chronic pain

The reviews of these “alternative” treatments have already been done and didn’t find them particularly helpful. If there was pain relief, it was generally not much for not many.

You can read all the non-opioid pain treatment studies in these lists of Cochrane Reviews:

These lists of treatment reviews were compiled by the Inspire.com member, “Seshet” – thank you!