Living With CDC Opioid Guidelines
Not quite a year has passed since the Centers for Disease Control and Prevention (CDC) published its guidelines for opioid prescribing.1 Although the guidelines may have been drafted and published with the sincere intent of reducing opioid overdoses, the consequences of the guidelines have been profound.
Among its recommendations, the CDC noted that “clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligrams equivalents [MME] or more per day, and should avoid increasing dosage to 90 MME or more per day.” The maximum of 90 MME is a guideline, not law or even a regulation. Thus, the guidelines don’t restrict opioid dosages above 90 MME. They also do not cover use of opioids in the palliative, end-of-life, and cancer settings. It is, therefore, fitting that my Editor’s Memo to start 2017 concerns the consequences of CDC opioid guidelines.
The first consequence of the guidelines is a growing distrust that pain patients and their advocates feel toward the CDC and other governmental agencies. Although a year has passed since the CDC held public hearings on the guidelines, claims of fraud, deceit, and hidden agendas are a continued focus of investigations. Most recently, a report published in JAMA Internal Medicine suggested that some of the opposition to the CDC guidelines expressed by professional groups may have been influenced by existing financial interests with opioid manufacturers and other stakeholders.2
Pain News Network, a patient advocacy website, surveyed more than 2,200 chronic pain patients before the release of the CDC guidelines.3 Many of the respondents predicted there would be unintended consequences if the guidelines were adopted:
- 90% thought more people would suffer from than be helped by the guidelines
- 78% thought there would be more suicides
- 76% thought doctors would prescribe opioids less often or not at all
- 60% thought pain patients would get opioids through other sources or off the street
- 70% thought use of heroin and other illegal drugs would increase
There is hardly a patient I see who fails to express similar concerns. Whether these perceptions have any merit seems less important than the reality that setting limits on opioids have created a wall of mistrust and a perception that some government officials care more about the addict than a suffering pain patient.
Dissemination of Nonscientific Information
Another consequence is that a small group of medical practitioners who bill themselves as “pain experts” have attempted to capitalize on the new guidelines. Some of the unscientific claims I’ve recently heard include:
- No pain patient ever needs over 90 MME
- Anyone taking over 90 MME has hyperalgesia
- Severe risks and complications are inevitable with dosages over 90 MME
- There are no “long-term” benefits of doses over 90 MME
In addition, some 3rd-party payors are misinformed about opioid dosing and side effects. I recently received a telephone call from a 3rd-party payor who admonished me to give patients naloxone, since “every” patient prescribed over 90 MME “will eventually overdose.”
My fundamental answer to all these nonscientific, often hysterical beliefs is to recommend a visit to any pain practice in the country to seek out a couple of patients who have been on a fentanyl patch for a few years. Any patch above 25 mcg/h exceeds 90 MME. Don’t be shocked when you find out that patients using dosages of greater than 25 mcg/h are functioning well, with no known complications or hyperalgesia. Why should they throw away their patches just to meet a 90 MME recommendation?
Loss of Coverage
The next consequence is that insurance companies (including workers’ compensation carriers) and some state legislatures and medical boards now consider the 90 MME level a ceiling or maximal opioid dose. This has led to denial of claims for prescriptions over 90 MME. Pain News Network conducted a follow-up survey of 1,978 chronic pain patients and found that 68% said their opioid medication had been decreased or stopped since the CDC adopted its prescribing guidelines.4 In addition, 45% of respondents were warned by their doctor that additional decreases would be necessary. Most striking, just over 50% said they had considered suicide as a way to end their pain.4 Additional survey findings included:
- 75% of patients said they are not receiving adequate pain control
- 57% said they had been discharged or abandoned by a doctor because they need opioid treatment
- 44% said they had problems getting a prescription filled at a pharmacy
- 90% said their pain levels, activities, and social interactions have worsened
- 97% said they have never been addicted to drugs or required treatment for drug abuse
Moreover, many doctors fear scrutiny by their medical boards (ie, medical license restriction or revocation) and the Drug Enforcement Agency if they prescribe above this level. Some physicians have informed me that they can’t get malpractice insurance or local hospital privileges if they prescribe above 90 MME. Given these developments it’s no wonder that physicians in primary care, as well as specialty sectors, are now simply refusing to prescribe opioids at all, and certainly not above 90 MME.
Another unfortunate consequence is growing, unconfirmed anecdotal reports on patient-oriented Internet sites of suicide or cardiovascular collapse among chronic pain patients who have had their opioids abruptly reduced because their physician refused to prescribe or an insurance company refused to pay for opioids above 90 MME. Many longtime chronic pain patients are resistant to attempts to lower their opioid dosage to 90 MME. Many of these patients were started many years ago on dosages considerably over 90 MME. They have not only functioned well but often found a good quality of life despite severe injury or disease, and they consider their opioids to not only be a right but their very lifeblood. New chronic pain patients usually are far less problematic since there are now many opioid alternatives that help keep the opioid dosages below 90 MME.