Amidst growing concerns about the opioid epidemic, in 2016 the CDC released its “ Guideline for Prescribing Opioids for Chronic Pain.” The stated purpose of the guideline was to “provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”(1)
With the new guidelines in hand, federal agencies, state governments, insurers and many doctors rushed to implement the recommendations as quickly as possible. The problem is that too often the guidelines were misinterpreted and misapplied.
CDC Guideline Authors Say Many Opioid Prescribing Laws Go Too Far
In a perspective article published in The New England Journal of Medicine on April 24, 2019, the authors of the 2016 CDC guidelines said, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.”(2)
A consensus panel report, published in the April 2019 issue of Pain Medicine also highlights the inconsistencies noted by the guideline authors.(3) Two of the inconsistencies are particularly alarming––and even dangerous.
1. Inflexible application of the recommended maximum doses and the length of time opioids may be prescribed
The guideline authors stressed that their guidelines and recommendations were just that––general guidelines and recommendations based on the best available evidence of what should work well for most patients. They were never intended to be hard and fast laws that fail to take into account the needs of individual patients.
Unfortunately, many state legislatures ignored that fact and almost immediately began enacting laws that placed strict limits on opioid prescribing. As of October 2018, at least 33 states had enacted such legislation.(4)
The results have been devastating for many chronic pain patients. Instead of being helped to gradually taper off of opioid medication, as recommended by the FDA and the CDC guidelines, some patients were simply cut off without warning. They suddenly found themselves in the throes of horrible opioid withdrawal symptoms with no one to help them.
Another group of chronic pain patients seriously harmed by these inflexible laws were those who had been taking large daily doses of opioid medication. The CDC 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.” This recommendation was never intended to apply to patients who were already taking daily doses above 90 MME, yet many of these patients were abruptly dropped to 90 MME/day or less––again without being helped to taper down gradually. Often this action brought on severe opioid withdrawal symptoms and left them in excruciating pain.
2. Misapplication of the recommendations to include patient populations outside the scope of the guidelines
The CDC guideline was specifically written for the treatment of chronic pain patients. It’s even included in the title of the document. The recommendations were never intended to be applied to patient populations outside of the chronic pain community, such as cancer patients, people receiving end-of-life care, patients undergoing major surgical procedures and people in acute sickle cell crisis. Yet there have been numerous reports of the chronic pain guidelines being applied to these patient groups.(3)
The Unintended Consequences of Opioid Medication Prescribing Restrictions
The nationwide concern about the opioid epidemic is understandable. We all want to eliminate drug addiction and prevent deaths from accidental drug overdoses. But enacting inflexible laws that unfairly penalize chronic pain patients and prevent doctors from providing adequate care for their patients is not the way to do it.
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It’s also important to note that these laws are not accomplishing the ultimate goal. Lawmakers may boast that because of these increasingly restrictive laws, prescriptions for opioid medications have dropped 43% since 2011. What they may not tell you, however, is that addiction and overdose rates have continued to soar.(5)
How is that possible? Because many chronic pain patients, whose doctors have refused to continue prescribing or drastically reduced the dosage of their opioid medication, are either turning to black market sources or switching to an illegal drug like heroine in order to obtain adequate pain relief. As a result, patients who were once being safely treated and monitored by their physicians, are now left to either suffer severe ongoing pain or take their chances with illegal and dangerous, potentially tainted, drugs. Sadly, when faced with these two equally bad options, some patients have chosen to end their lives.
We hear lots of dramatic, heartbreaking stories in the news about drug overdoses and the dangers of opioids, but this is the story that is rarely told. It’s the story of millions of chronic pain patients who are being trampled under foot in the rush to enact increasingly stricter laws to restrict the prescribing of opioid medications.
As Paul Harvey used to say, it’s time to tell “the rest of the story.” We need to let the public in general and our lawmakers in particular know the unintended consequences their legislation is having on patients like us––patients with a chronic illness like fibromyalgia, ME/CFS (myalgic encephalomyelitis / chronic fatigue syndrome), Lyme disease or other chronic pain syndromes––who live with daily, debilitating chronic pain.
Here’s How You Can Help
You can help tell the rest of the story. The best way to spread information in today’s world is on social media. People––including politicians––pay attention to what they see on Facebook, Twitter and other social media sites. It’s one way they gauge how their constituency feels about important issues. It’s very unlikely that lawmakers will ever read an article on the subject in a medical journal, but if they see it on social media, they may pay attention.
It’s not easy to get laws changed, especially when they relate to opioids. But if we make enough noise that lawmakers begin to understand just how much these laws are hurting innocent people who are already suffering, then we have a chance at influencing change.
So share this article, or the journal article written by the CDC guideline authors, or your own personal story about how the new opioid prescribing laws have harmed you on your social media pages. If we speak loudly enough and often enough, maybe the people who can really make a difference will begin to pay attention.
Karen Lee Richards is ProHealth’s Editor-in-Chief. A fibromyalgia patient herself, she co-founded the nonprofit organization now known as the National Fibromyalgia Association (NFA) in 1997 and served as its vice-president for eight years. She was also the executive editor of Fibromyalgia AWARE magazine. After leaving the NFA, Karen served as the Guide to Fibromyalgia and Chronic Fatigue Syndrome for the New York Times website About.com, then worked for eight years as the Chronic Pain Health Guide for The HealthCentral Network before coming to ProHealth. To learn more about Karen, see “Meet Karen Lee Richards.”
1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain––United States, 2016. JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464.
2. Dowell D, Haegerich TM, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med. 2019 Apr 24. doi: 10.1056/NEJMp1904190.
3. Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report. Pain Med. 2019 Apr 1;20(4):724-735. doi: 10.1093/pm/pny307.
4. Prescribing Policies: States Confront Opioid Overdose Epidemic 2018. http://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.aspx. Accessed May 30, 2019.
5. Record Decline in Opioid Prescriptions 2019. https://www.painnewsnetwork.org/stories/2019/5/11/opioid-prescriptions-drop-17-in-one-year. Accessed May 30, 2019.