For millions of Americans with chronic pain, the new opioid prescription guidelines issued by the Centers for Disease Control and Prevention may not be coming soon enough.
We also have an interest. One of us, Kate Nicholson, used prescribed opioids so she could continue to work as a civil rights attorney in the U.S. Department of Justice. (One surgical injury left him bedridden from the early 1990s to the late 2010s.) Another, Sally Satell, a psychiatrist who understands the risks of addiction, and how those risks are often overpaid when treating long-term patients. – Periodic pain.
The CDC’s 2016 “Guidelines for Prescribing Opioids for Chronic Pain” created havoc. Regulators, insurers, pharmacies, physicians, and law enforcement have misinterpreted the document as an official order directing doctors to limit the use of opioid painkillers or stop prescribing opioids altogether. Although the guideline, written in the Opioid Crisis, recommended limitation of prescribed painkillers, it was only issued. Guide, And not the proximity ban many have explained it. Yet the result is (and still is) that thousands of Americans who were in pain because of medical conditions did not receive the necessary pain medication or treatment.
Patients who have been doing well for years are confined to the couch because they do not have the necessary medication. Others have withdrawn from abrupt opioid withdrawal, sometimes turning to street medications for pain relief. Many “painful refugees”, as the media tell them, searched desperately for care when their doctors abandoned them. Some have even committed suicide.
We’ve spent the last few weeks reading every word, table, and quote from the CDC’s draft “Clinical Practice Guidelines for Prescribing Opioids,” an updated guide to pain treatment. (Full disclosure: Nicholson was a member of the Opioid Workgroup that reviewed previous versions of the new guide.)
Fortunately, the CDC’s 211-page update explicitly acknowledges the disadvantages that have arisen from previous versions and has made significant improvements. Above all, the new guidelines support the core philosophy of humanitarian care – surprisingly absent from the 2016 guidelines – that is, doctors should rely on their clinical judgment, not specific guidelines. The new document, its drafts firmly states, “should not be used as a rigid standard of care. [nor] Will be implemented as an absolute limit of policy or practice. “
Intelligently, the new recommendations equate to more than 90 milligrams of MME-morphine, a standard dose measure-removing the earlier warnings against daily prescriptions and omitting previous instructions that prescriptions should rarely last more than three to seven days. These two commonly misapplied provisions from the 2016 guidelines.
The value of these changes cannot be overstated, and yet other aspects of the update are annoying and threaten to destroy them.
For example, CDC updates send mixed messages. The emphasis on welcoming updates and personalized care has been undermined, for example, by a clear statement that opioids are “not the treatment of choice” for non-acute pain. Considering the drug “not preferred” gives insurers a convenient reason to refuse opioid coverage for serious conditions. For some patients and conditions, opioids Is Appropriate choice. A patient may have run out of other options, experienced worse side effects from them, or benefited so much from opioids that the value is clearly greater than the risk.
Another problem with the new draft guideline is that the updated text instructs physicians “Pause and carefully re-evaluate” (Darker in the original language) If they increase the dose above 50 MME per day. (A 10 mg tablet of oxycodone is equivalent to about 15 mg of morphine, or 15 mg.) While not theoretically bad advice, setting a dose threshold is a set-up for physicians and policymakers to take it as a ceiling and not. A suggestion.
This is exactly what happened when the 2016 guideline asked physicians to justify prescribing more than 90 MMEs a day. Instead of explaining their decisions, nervous clinicians, fearful of law enforcement or lawsuits, seized the 90mm dose as a decree to reduce all amounts below that threshold. A tight limit of 50 mmE in the updated guidelines threatens to produce worse results.
Finally, to review the evidence for the treatment of long-term pain opioids, the draftsmen excluded studies that did not last more than one year, which strangely violated the CDC’s own definition of chronic pain, pain that lasted three months or more, not one year. Or more. Furthermore, exempting these studies removes existing evidence from the draft that opioids can reduce pain for more than three months.
The guide recommends opioid alternatives such as acupuncture, laser therapy and massage, which may be good for some patients. But many insurers do not cover these options, making them effectively unavailable to some patients, as the CDC itself acknowledges.
But what worries us the most is that physicians, healthcare agencies, states and law enforcement may ignore the guidelines’ strict prohibitions against patient abandonment, strict dose cutoffs and unintentional tampering.
We have already seen that doctors and pharmacies refuse opioid drugs for patients with cancer and sickle cell disease, as well as for palliative care patients, although the 2016 guidelines explicitly exempt them from the recommended restrictions.
In 2019, we requested that the CDC clarify its guidelines মাধ্যমে through a widely circulated letter from Nicholson in collaboration with Human Rights Watch and Seattle, signed by more than 300 concerned physicians. To its credit, the CDC issued a revision in April 2019 New England Journal of MedicineWarn doctors and healthcare systems against the “inflexible application” of the guidelines.
We were thrilled – and then nothing happened.
Nicholson, executive director of the National Pain Advocacy Center, an organization that fights for the pain treatment available to those in need, receives numerous messages each week from patients suffering from cancer or late-stage excruciating pain. Multiple sclerosis or amputation. Every story of suffering in his in-box is as heartbreaking as it is unnecessary.
If the CDC’s bold clarification in a leading medical journal had little effect on regulation and practice, would the organization’s new advice against patient abandonment be enough?
We are skeptical of the benefits of retrospect.
Here’s what really helps at this point: The CDC needs to develop its final guidelines in a way that minimizes the potential for policy misapplication. It is not enough to say the guideline voluntarily, when we know it will be interpreted as a national prescribing mandate. This is especially important because the new guidelines are much broader; This will be practically applicable to medical treatment All Pain, not just chronic pain. The agency should, in incredible language, refer to physicians, healthcare systems, insurance companies and government entities that, because pain intensity and underlying conditions vary widely, personalized care is paramount.
The CDC also needs to be proactive in dealing with bureaucratic pressures. It must discourage other federal agencies, such as the Center for Medicare and Medicaid services and the Drug Enforcement Administration, from imposing blanket-setting thresholds on doctors. This is an opportunity for CDC Director Rochelle Walensky to get out of the controversy over the COVID-19 policy. As a physician at the forefront of the HIV / AIDS epidemic, Walenski has witnessed human suffering and stigma that could deny people at the center of a public health crisis what they probably need most: appropriate and humane access care.
With its updated guidelines, the CDC has the potential to correct significant, if unintentional, damage. But this will only happen when the practical knowledge that it now supports is put into practice.