On Wednesday, the Centers for Disease Control and Prevention (CDC) issued a clarification regarding the federal guidelines for opioid prescriptions that were put into place in 2016. The paper, published by CDC researchers in the New England Journal of Medicine, stated that many of the guidelines have been misapplied, causing serious harm to chronic pain patients.
The original prescribing guidelines were intended for primary care physicians treating adults with chronic pain (pain that lasts more than three months) outside of active cancer treatment, palliative care and end-of-life care.
“The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the number of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs,” the CDC wrote.
While many medical and health policy communities embraced the guidelines, CDC researchers said some clinicians and policy-makers have misinterpreted them, taking the recommendations too far.
The paper published this week reported that some physicians have encouraged “hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician’s practice.” The guidelines have also been mistakenly applied to patients with pain associated with cancer, surgical procedures or sickle cell crises – patients who were not included in the original recommendations.
CDC researchers offered several examples of the ways in which their guidelines had been wrongly implemented. They wrote:
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.’ 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.
This misapplication can have major consequences for people with chronic pain. Researchers explained that forcing patients to abruptly taper their dosages can lead to opioid withdrawal, increased pain or other adverse psychological and physical outcomes. Too little is known about the benefits and harms of reducing high dosages of opioids in physically dependent patients for researchers to recommend this strategy to physicians.
Mighty contributor Chris Jolley was one of many people with chronic pain adversely affected by these misimplemented guidelines. In his essay “When a Doctor Forced Me to Taper Off Pain Medication,” he wrote:
I was with my pain doctor on the same medication for 20 years when the medications that control my chronic pain were stopped without my consent. …
I live in unbearable pain 24/7. I’m one of the many people in pain whose doctors have abandoned us and ignored our pleas for help. Many pharmacists profile us based on their perception of our appearance. Some will not even fill prescriptions from cancer patients.
I have disability benefits awarded by my government for intractable pain, yet I suffer discrimination and cannot get treatment for that pain. Until our government admits the epidemic is about street drugs like fentanyl and heroin and stops persecuting people in pain, there will be more and more deaths by overdose from street drugs and more pain patients suffering.
Since the CDC’s guidelines were published in 2016, the number of opioid prescriptions has decreased. In May 2018, SERMO, a social network for physicians, conducted a study of 3,000 physicians and found that seven out of 10 said they cut back on prescribing opioids or stopped prescribing them entirely in the last two years. When SERMO conducted the same study in 2016, six out of 10 doctors said they were cutting back.
Among doctors who had cut back, 22 percent said it was because there were “too many hassles and risks involved,” while 34 percent said chronic pain patients have been hurt by the reduction in opioid prescriptions.
Research has shown that limiting opioid prescriptions does not have an effect on the rates of death and addiction in the U.S. According to reports from the CDC, opioid deaths in the U.S. are rising, with a 9.6 percent increase from 2016 to 2017. But this increase is due to fentanyl, not prescription opioids.
Researchers said the CDC is examining the impact its 2016 guidelines have had on pain patients and will update them when new evidence is available. “Until then, we encourage implementation of recommendations consistent with the guideline’s intent,” they said.