CDC Guidelines for Opioid Tapering in Chronic Pain, what’s missing?

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By R Carter

The CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 was a landmark publication by the CDC in its efforts to curb opioid abuse and misuse. But linking efforts at thwarting illegal opioid abuse with prescribing for legal and legitimate medical need, is by any standard misdirection, not unlike trying to minimize diabetics who have insulin reactions, by limiting access to insulin. 

Looking back after more than three years the damage is evident, the CDC guidelines have only fueled the flames of opioid hysteria, encouraging many in the healthcare profession to go too far, even mainstream media such as USA Today are taking notice. The misapplication of those guidelines has resulted in the following.

Consequences of Opioid Hysteria

  • Reductions in amounts of opioids used for acute pain scenarios, such as surgery which has only increased the pain and suffering of those undergoing elective and emergent procedures.
  • Forced tapering or termination of opioids in chronic pain patients who have legitimate medical need and have been stable and compliant with their use for years and in some cases, decades.
  • Complications with comorbid patients leading to adverse events such as heart attacks, stroke, death or suicide.
  • Advocating the use of IV acetaminophen as a substitute for opioids without sufficient medical investigation to support such treatments, resulting in gastrointestinal bleeds and liver damage.
  • Non-health related consequences such as loss of employment, an increase in applications for Social Security, Welfare, Medicaid and disability.
  • The intrusion of legislators into the judgement and decision making of medical professionals.
  • The overzealous reach of law enforcement into the prescribing practices of physicians.
  • The restriction of physician judgement and practice by state medical boards with fixed caps and limits on opioid prescribing.

These are just the some of the more severe consequences. The Don’t Punish Pain Rally National Facebook page has over 10,000 members who daily verbalize the consequences they’re suffering as a results of opioid hysteria within the ranks of our healthcare profession.

So what are our healthcare professional and law enforcement agencies failing to recognize in their efforts to balance combating opioid abuse while humanely and responsibly managing chronic pain conditions for the public?

  1. Prescribers are the gatekeepers for dispensing opioids, they hold the keys and as such they need flexible guidelines which both protect the public from abuse but not at the expense of treating those with a legitimate medical need.
  2. Rational and humane guidelines for tapering or terminating opioids while respecting the clinical judgement of the prescriber for their use.
  3. Clearer boundaries for law enforcement and the DEA, boundaries which recognize the right of due process, in their efforts to prosecute suspected or charged offenders.
  4. Adoption by the CDC of the recommendations published by Pain Management Best Practices Inter-Agency Task Force
  5. With regards to chronic pain management and regulations adopted by state medical boards, recognition and inclusion of the following elements into prescribing guidelines.
    1. Specific medical conditions known to produce chronic, long standing, non-cancer pain.
    2. Body mass difference when calculating opioid dosages.
    3. A differential constant to be applied to opioid dosing calculations which accounts for the development of tolerance, a known and recognized complication of long term opioid treatment.
    4. The elimination of fixed caps and limits which have no regard to FDA prescribing literature.

Nearly every chronic pain patient I speak to has no objection to the current efforts to eliminate opioid abuse and misuse. What they do object to is the continued assertion of irrational fears which taints our current efforts at striking a balance between meeting the medical needs of the public and combating the illegal elements which are flooding our country with non-medical drugs.

The efforts of the chronic pain community are having an effect. Since January 2019, we’ve seen more healthcare professionals step up and callout those, whose efforts are tainted by irrational ideology or fear. State Medical Boards are listening, and adopting some of the recommendation made above, but many are not and the chronic pain community needs to continue its efforts at speaking to these groups, urging rational and actionable steps which don’t result in throwing the baby out with the bathwater.

Some of those efforts can be seen in the recommendations adopted by Pain Management Best Practices Inter-Agency Task Force, the CDC Pocket Guide: Tapering Opioids for Chronic Pain and the State Medical Board of Ohio Guidelines for Prescribing Opioids for Chronic Pain.

As long as pseudoscience, such as this publication,  The risk of a single 5-day opioid prescription, in one chart is allowed to continue, the public’s best interest is not being served. Such extreme and irrational rhetoric must be removed from the practice of medicine and healthcare professional must be allowed to return to the tenants of doing no harm.

 

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