Overall, we have every reason to believe that the opioid crisis is getting better, not worse. Since the Centers for Disease Control issued its guidelines dictating appropriate opioid prescription rates and dosages in 2016, opioid prescriptions have declined significantly. Overdose deaths have also been on the decline, though some health experts believe that effect might be temporary.
Two groups that have not benefited from increasing public health efforts to stem the opioid crisis, however, is people living with chronic pain and their health care providers. In a letter to the CDC that was published on Wednesday, a coalition of health care providers, doctors and patient representatives, writing on behalf of an organization called Health Professionals for Patients in Pain (HP3), issued a call for the CDC to “address misapplication of its guideline on opioids for chronic pain through public clarification and impact evaluation” — in short, to clarify its guidelines on opioid prescription for doctors, particularly when it comes to weaning patients off the drugs.
“Patients with chronic pain, who are stable and, arguably, benefiting from long-term opioids, face draconian and often rapid involuntary dose reductions,” the letter states. Often, alternative pain care options are not offered, not covered by insurers, or not accessible. Others are pushed to undergo addiction treatment or invasive procedures (such as spinal injections), regardless of whether clinically appropriate. Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
“There’s no question that doctors have [historically] been too liberal in prescribing opioids,” says Sally Satel, MD, a psychiatrist and a lecturer at the Yale University School of Medicine, who coauthored the letter. “But in this pulling back, the pendulum has overshot in some instances, and it’s especially taken a toll on people who have been maintained on usually high-dose opioids for many years for excruciating chronic conditions.”
— Stefan Kertesz (@StefanKertesz) March 7, 2019
Currently, the CDC guidelines on opioid prescription recommend that doctors attempt to get patients to taper off the drugs. They also recommend that doctors avoid prescribing opioids for long-term pain management, and that any daily dosage should be below the equivalent of 90 milligrams of morphine.
While the guidelines are not strictly enforced — “these are guidelines, not mandates,” Satel says — they have prompted many states to pass laws regulating opioid prescriptions, and many health care providers to try to wean patients with chronic pain off opioids, which can prompt patients who have been on opioids for years to experience withdrawal symptoms. As an example, Satel cites a woman with interstitial cystitis (essentially chronic bladder inflammation) who receives 40 mg of methadone for 35 years to manage her pain, until her doctor informed her he would not be prescribing her methadone anymore. “It was an abrupt notice, and she panicked,” Satel says. The woman found another doctor to prescribe her the methadone and continued maintaining the dose. “Luckily it had a happy ending [for her], but for so many it doesn’t.” (In response to the letter, a spokesperson told the New York Times that the guidelines “do not endorse mandated or abrupt dose reduction or discontinuation.”)
In some cases, the resulting chronic pain is so severe that it can lead patients to take their own lives, though the CDC doesn’t have any statistics documenting the exact prevalence of this phenomenon (though one of the signatories of the letter, Anne Fuqua, is a former registered nurse who is currently compiling accounts of such cases from the family members of those who have been subject to involuntary tapering). “Sometimes the patients leave letters who are explicitly drawing the connection,” says Satel. “They were managing, and the doctor took them off, and they say, ‘I can’t live with this pain.'”
Of course, given the clear link between prescription opioid use and long-term addiction (CDC data indicates that more than 240,000 people died of prescription opioid overdoes between 1997 and 2017, with five times as many deaths in 2017 versus 1999), the letter begs the obvious question: how, exactly, can doctors determine whether someone is using prescription opioids to manage their chronic pain, or if they are truly addicted? And can you predict whether someone will become addicted to opioids, even if they are initially prescribed to manage a legitimate health condition?
Satel doesn’t have a clear answer for this: “You can’t predict with 100-percent accuracy, but people who are at higher risk of becoming addicted are people with a history of addiction, people who have a psychiatric diagnosis or who are just struggling with significant existential problems,” she says. She estimates that the “majority” of those who are prescribed opioids will not develop addictions to them, which seems somewhat generous given the millions of Americans who already have. (It’s also worth noting that the Times reports that some of the 300 signatories of the letter are patient representatives who have taken money from the pharmaceutical industry, though Satel says she didn’t know precisely how many.)
Nonetheless, the general takeaway — that, in trying to remedy a national health crisis, some health care providers may have over-corrected, and in so doing harmed those who could truly benefit from such medications — is one that is also supported by the American Medical Association (AMA), which issued a statement in 2018 saying that some patients “with acute or chronic pain” could benefit from doses higher than those recommended by the CDC guidelines.
Ultimately, Satel is clear that the intention of the letter is not to prompt the CDC to revise its guidelines entirely: “these aren’t bad guidelines at all,” she says, nor should medical providers be totally reliant on prescribing opioids to manage chronic pain. She would, however, like individual health care providers to “use common sense, on a patient-by-patient basis” when prescribing opioids. She is also pushing for the CDC to issue a press conference clarifying its guidelines and to “make clear to doctors and patients there is no federal requirement to alter the dose of medication for someone who is maintained successfully on opioids for chronic pain. Just make that loud and clear: the DEA will not kick down your door if you’re being maintained on high doses.”