Thomas Kline, MD, PhD, refers to 22 of his patients as “pain refugees.”
Stable for years taking opioid therapy for chronic pain, these patients sought out Kline—well-known for his advocacy on their behalf on Twitter and elsewhere—because their physicians had abruptly cut their dose or refused to refill a prescription.
They had appealed to multiple physicians for treatment with no success before contacting him, said Kline.
Kline accepts these patients that no one wants because he’s trying to keep them off another list, one he has helped compile: a list of US residents believed to have committed suicide because their physicians would no longer prescribe adequate doses of opioids to treat their chronic pain.
As of late April, the list was 40 people long, but it is not inclusive, Kline said. “The problem is a lot of families don’t want this public. I have to respect that.”
“Chaotic and Brutal”
The CDC guideline recommends that physicians carefully reassess potential benefits and risks when considering whether to increase a patient’s dose to 50 or more morphine milligram equivalents (MMEs) per day (MMEs are used to compare doses of different opioids)
Although that recommendation relates to patients who have not yet started taking opioids for chronic pain, it has also been widely interpreted as a target for the millions of users who long ago surpassed 90 MMEs a day
…editorial, titled “We Cannot Treat the Dead,” questioned whether the marked increase in US suicide rates might be related to inadequate pain treatment, as a CDC study noted that 22% of suicides in 2015 reportedly occurred among people with documented physical health problems.
In April, CDC Director Robert Redfield, MD, responded to the letter Kertesz coauthored, noting that “[t]he Guideline does not endorse mandated or abrupt dose reduction or discontinuation, as these actions can result in patient harm.”
Two weeks later, the authors of the 2016 guideline echoed Redfield’s letter in a Perspective piece published in the New England Journal of Medicine.
“Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations,” the authors wrote.
This disaster is far more than merely “unfortunate” when it’s actually killing people. While these high level “leaders” muck around with layers upon layers of rules about access to medically necessary medications, patients in intractable pain are left with only one way out of their suffering, suicide.
Noncancer vs Cancer Pain
While the CDC’s opioid-prescribing guidelines were intended for noncancer chronic pain, physicians report that it has been used to block treatment of patients with cancer pain.
In a February letter, a CDC official responded to 3 medical organizations that had expressed concern over how misinterpretation of the agency’s guideline was affecting patients undergoing cancer treatment, cancer survivors with chronic pain, and people with sickle cell disease.
This distinction is simply not valid, no matter how many still believe it or continue to cite it: NO DIFFERENCE between cancer and non-cancer pain
The CDC guideline notes that “there is now an established body of scientific evidence showing that overdose risk is increased” at higher opioid dosages, but the guideline doesn’t cite evidence specifically supporting the 90-MMEs cutoff.
That’s because there is no such evidence. The 90MME cutoff was essentially arbitrary.
A previous post, Impact of High-Dose Opioid Analgesics on Overdose,
shows that the CDC’s 90mg “threshold” is merely one of convenience and does not exist in “real life”.
some North Carolina patients with chronic pain have said their physicians stopped prescribing opioids and, by way of explanation, handed them a copy of the state’s 2017 Strengthen Opioid Misuse Prevention (STOP) Act, which limits initial prescriptions for acute pain to 5 or 7 days. The STOP Act specifically states that the limits do not apply to chronic pain
I find it impossible to believe that doctors are so ignorant, that they
- can’t tell the difference between guidelines for acute pain versus guidelines for chronic pain,
- don’t know that only acute pain is limited while chronic pain is lifelong,
- don’t understand that patients with long-term make pain will need long-term opioid prescriptions as well.
And yet, a quarter (663) of the 2661 physicians who responded last fall to a survey by the North Carolina Medical Board said they had stopped prescribing opioids for chronic pain.
The Pendulum Swings
Prescribing increased in the first decade of the 21st century for 2 main reasons:
- the concern that chronic, noncancer pain was not being adequately treated and
- the downplaying of opioids’ risks and overstating of their benefits by manufacturers
Management of pain became a quality measure, incentivizing physicians to prescribe large doses to stomp it out.
As if this were possible!
Those of us with disabling high impact chronic pain know that “stomping out” our pain 100% is impossible unless we’re unconscious. I would be ecstatic to get 90% pain relief, thrilled to achieve 80%, pleased at 70%, and glad for even a 60% reduction in my pain.
Anyone expecting 100% relief seems completely unrealistic and just plain greedy.
Multiple factors account for why patients with chronic pain have ended up taking high doses of opioids.
“Tolerance is certainly one of them,” said Joanna Starrels, MD, MS, an internist and addiction medicine specialist
Patients’ pathology might have changed over time, and they might have new pain sites, she added.
They’ve missed the most pertinent and more obvious reason: Aging.
With a chronic condition, our body’s breakdown is accelerated because it doesn’t hold up as well against the normal deteriorations that accumulate over the years.
“In addition, we’re learning about opioid-induced hyperalgesia,” Starrels said, referring to a little-understood phenomenon in which long-term opioid exposure is thought to increase pain sensitivity, possibly leading to higher doses.
How can intelligent people keep repeating this nonsense? Hyperalgesia has only been confirmed in rodent experimental conditions, never in humans or in clinical conditions.
Here are several posts showing that hyperalgesia is NOT a known issue for patients taking opioids as directed:
- The Truth About Hyperalgesia –
Demystifying Opioid-Induced Hyperalgesia – By Jennifer P. Schneider, MD, PhD – Feb 2019 Some insurance companies have declined to continue paying for opioid medications, citing OIH. Here’s why. In cases like these, many insurance companies state that patients should have their doses tapered in order to decrease their pain. Now, we’re really living in a fun-house…
- High Quality Study Shows NO Hyperalgesia
Analgesic tolerance without demonstrable opioid-induced hyperalgesia: a double-blinded, randomized, placebo-controlled trial of sustained-release morphine. – PubMed – NCBI – Pain. 2012 Aug This is the highest quality of research design: double-blinded, randomized, and placebo-controlled – you can ask for nothing more – and it showed NO hyperalgesia. Although often successful in acute settings, long-term use of opioid…
- Inflammation → Hyperalgesia → Chronic Pain
C-reactive protein and cold-pressor tolerance in the general population: PAIN – July 2017 I’m reposting this study because it explains that hyperalgesia, which is blamed on opioids, arises from chronic inflammation and the numerous chemical changes this causes in the body over time…
- Diagnosing Hyperalgesia to Limit Care
The CDC guideline is reasonable for patients who are just starting opioid therapy for chronic pain, but it’s not meant to be retroactive, noted internist Margaret Lowenstein, MD,
I don’t think the CDC guideline is unreasonable – if it’s simply read as very general guidance for non-experts. If our pain medications were of any other class of drugs, like blood thinners or cholesterol-lowering drugs, there would be little controversy.
However, the guideline was written from an addiction specialist’s viewpoint and barely mentions the indispensable function of these medications to relieve debilitating pain. Instead, it exclusively advises on how to avoid a rare side-effect (addiction can occur in less than 5% of cases) with a relentless focus on milligrams prescribed.
Tapering as Opposed to Chopping
The CDC is supporting 4 extramural research projects examining the unintended consequences of tapering and discontinuation, according to an enclosure accompanying Redfield’s letter to Kertesz and colleagues.
Even though I scan much of the medical literature on pain and opioids, I have not seen a single mention of such studies until now.
I’ve also never heard of “extramural” research projects, which would seem to describe projects taken on by other agencies/groups, not the CDC itself, despite their promises to do so in the guideline itself.
To verify my suspicions, I looked it up:
Extramural Research has been defined 2 different ways in documents like Glossary of NIH Terms, National Institute of Food and Agriculture Glossary.
- as defined in Glossary of NIH Terms by U.S. Department of Health and Human ServicesU.S. National Institutes of HealthU.S. National Institutes of Health, Office of Extramural Research: Research supported by NIH through a grant, contract, or cooperative agreement.
- as defined in National Institute of Food and Agriculture Glossary by U.S. Department of Agriculture, National Institute of Food and Agriculture: Grants and contracts to outside institutions or schools to help pay for research projects and resources.
So it seems the CDC is going against its own guideline, which committed it to study the outcomes of these guidelines and is letting other groups follow up instead.
As far as I know, no such study on outcomes has been initiated by the CDC.
Spurred by reports of serious withdrawal symptoms, uncontrolled pain, and suicide in patients whose opioid doses were abruptly stopped or cut, the FDA announced new opioid labeling changes in April to better inform physicians how to properly taper patients
Reduce Doses, Reduce Overdoses?
Intuitively, it makes sense that limiting opioid prescriptions would help reduce overdose deaths, Lowenstein said. However, she said, “the evidence is mixed at best.”
Sure, this would be true if overdoses were caused by pain patients taking their medication, but the deaths are caused by cocktails of various street drugs, not prescribed medication taken as directed.
While studies show that state prescription monitoring programs appear to have reduced potentially inappropriate opioid prescribing, that hasn’t necessarily translated into fewer overdose deaths, in part because most opioid overdoses are due to illicit fentanyl or heroin, not prescription opioids.