5 Myths About the CDC Opioid Guidelines – Aug 2016 – By Pat Anson, Editor
In a recent survey of nearly 2,000 pain patients, over two-thirds said their opioid medication has either been reduced or stopped by their doctor since the CDC’s opioid prescribing guidelines were released.
…a sign they are being rigidly adopted and implemented by physicians, regardless of the impact on patients.
Myth #1: The CDC prescribing guidelines are mandatory
False. The guidelines are voluntary and intended only for primary care physicians, yet they are being widely implemented by many prescribers, including pain management specialists and even some oncologists. Here is what the guidelines actually say:
“Although the guideline does not focus broadly on pain management, appropriate use of long-term opioid therapy must be considered within the context of all pain management strategies…The guideline offers recommendations rather than prescriptive standards; providers should consider the circumstances and unique needs of each patient.”
The voluntary nature of the guidelines was reinforced in a recent letter to a pain patient by Debra Houry, MD, Director of the CDC’s National Center for Injury Prevention,
Myth #2: The guidelines establish a limit on the highest dose of opioids
False. The guidelines recommend that prescribers should “use caution” when prescribing opioids at any dose and “additional precautions” when dosages exceed 50 mg (morphine equivalent) a day. Prescribers are warned to “generally avoid” increasing dosages over 90 mg a day, but are never told they cannot exceed it.
the dosing recommendations are mainly intended for new patients, not established patients who’ve been on high opioid doses for years without any problems.
For patients who agree to taper opioids to lower dosages, providers should collaborate with the patient on a tapering plan. Experts noted that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.”
many patients say they are being abruptly tapered to lower doses without having any input into the decision.
Myth #3: The guidelines require doctors to drop patients if they fail a drug test
False. The guidelines specifically recommend against this practice:
“Providers should not terminate patients from care based on a urine drug test result because this could constitute patient abandonment and could have adverse consequences for patient safety, potentially including the patient obtaining opioids from alternative sources and the provider missing opportunities to facilitate treatment for substance use disorder.”
It seems that patients who have been “fired” or “terminated” by their pain management doctors without sufficient time and prescriptions to taper could all sue their doctors for “patient abandonment”.
Yet patients tell us they’re being dropped after just one failed test.
As Pain News Network has reported, the point-of-care (POC) urine drug tests widely used by doctors are wrong about half the time — frequently giving false positive or false negative results for drugs like oxycodone, methadone, methamphetamines and antidepressants
According to one study, POC [point of care] tests give false positive readings for cocaine about 12 percent of the time, and they fail to find signs of marijuana – a false negative — about 21 percent of the time.
The CDC admits urine drug tests “can be subject to misinterpretation” but recommends their use anyway, before opioid therapy begins and at least once annually thereafter.
This is part of the unscientific terms of the guidelines. The recommendation of using a test whose results are known to be suspect goes against logic.
If “unexpected results” are found, the guidelines say they should be verified by more expensive laboratory tests.
Myth #4: The guidelines will help reduce opioid abuse and overdoses
The early results are not promising.
The prescribing of opioid pain medication was in decline years before the guidelines were issued, yet overdose death rates continued climbing.
In recent months, opioid overdoses in several northeastern states have spiked, with most of the deaths blamed on illicit fentanyl smuggled into the country from China, Mexico and Canada.
Most disturbingly, drug traffickers are learning how to manufacture counterfeit pain medication with fentanyl. The DEA says the U.S. is being “inundated” with hundreds of thousands of these fake pills.
It’s not just street addicts being victimized by the fentanyl scam. Some are pain patients who turned to the black market for relief because they could no longer get opioid prescriptions legally
Could the CDC have seen this coming? In its urgency to get the guidelines adopted, the agency never took a hard look at the unintended consequences the guidelines could have:
“Concerns have been raised that prescribing changes such as dose reduction might be associated with unintended negative consequences, such as patients seeking heroin or other illicitly obtained opioids or interference with appropriate pain treatment. With the exception of a study noting an association between an abuse-deterrent formulation of OxyContin and heroin use… CDC did not identify studies evaluating these potential outcomes.”
Myth #5: There are better alternatives than opioids
There are many different types of non-opioid medications, ranging from over-the-counter pain relievers like ibuprofen and acetaminophen to prescription drugs like Lyrica (pregabalin) and Neurontin (gabapentin). There are also several non-pharmacological treatments like acupuncture, massage, physical therapy, and cognitive behavioral therapy (CBT).
The CDC guidelines make it sound like these alternative treatments always work and are readily available to every patient:
“Many nonpharmacologic therapies, including physical therapy, weight loss for knee osteoarthritis, complementary and alternative therapies, psychological therapies such as CBT, and certain interventional procedures can ameliorate chronic pain.
Several nonopioid pharmacologic therapies (including acetaminophen, NSAIDs, and selected antidepressants and anticonvulsants) are effective for chronic pain
Selected anticonvulsants such as pregabalin and gabapentin can improve pain in diabetic neuropathy, post-herpetic neuralgia, and fibromyalgia.”
But when we asked over 2,200 pain patients what they thought about these alternative treatments, most said they didn’t work.
Three out of four patients said over-the-counter pain relievers “did not help at all” and 64% said the same about nonpharmacological treatments such as exercise and weight loss.
Non-opioid medications like Lyrica, Neurontin and Cymbalta fared a little better, with only about half of patients saying they did not help. But many also complained about side effects from the drugs, such as weight gain, anxiety and withdrawal symptoms
Some patients are being coerced into treatments they don’t want, such as epidural steroid injections.
Over a third of the patients recently surveyed by Lana Kirby, founder of Veterans and Americans United for Equality in Medical Care, said they have been told by a healthcare provider that they must have an operation or invasive procedure or they’ll no longer get opioids or be discharged from the practice
Coercion in medicine cannot be legal. It seems such behavior could be legally argued with the proper evidence.
Over half the patients (57%) in that survey said they had been discharged by a doctor because they required opioid treatment. Of those who were discharged, only half were able to find a new physician.
Perhaps the most telling response in that survey is that half of the patients admit considering suicide as a way to end their pain.
Suicide already takes more lives than opioid addiction: 2.5 Times more Suicides than Opioid Overdoses
In just five months, it is clear the guidelines are having a major impact on the pain community in the United States.
More people are suffering from untreated pain and more are dying from drug overdoses. Yet there is no sign the CDC has any intention to revise and clarify the guidelines or to dispel the myths that surround them.