The authors of influential federal guidelines for opioid prescriptions for chronic pain said Wednesday that doctors and others in the health care system had wrongly implemented their recommendations and cut off patients who should have received pain medication.
They said some health care players had used the guidelines to justify an “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages,” when the guidelines did not actually endorse those policies.
The new paper comes three years [of unrelieved agony and suicides] after the Centers for Disease Control and Prevention published the prescribing guideline.
The authors of the 2016 guidelines — Dr. Deborah Dowell and Tamara Haegerich of the CDC, and Dr. Roger Chou of Oregon Health and Science University — said in their new essay the recommendations were not meant to be used to withhold drugs from people who need them, and outlined instances of their misapplication.
The guidelines say that “clinicians should … avoid increasing dosage” to 90 or more morphine milligram equivalents per day or to “carefully justify” such a decision.
That did not mean prescribers should automatically cut dosages that were already above that threshold, the authors say, “yet it has been used to justify stopping opioid prescriptions or coverage.”
“We know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them,” they wrote.
And we won’t learn more anytime soon, because they are deliberately not tracking patient outcomes – even though these policies target those patients.
“Though some situations, such as the aftermath of an overdose, may necessitate rapid tapers, the guideline does not support stopping opioid use abruptly,” they write. They also argue that actions by some clinicians, such as halting opioid prescriptions or no longer seeing chronic pain patients, “could represent patient abandonment.”
I would suggest that there’s little doubt about this. Some people have sued for malpractice and won their cases:
From March 2016 until December 2017, an estimated 14.2 million fewer prescriptions were filled than if previous trends continued. There were nearly 1.3 million fewer high-dose prescriptions written, as well.
The CDC also recently responded to an ad hoc group of physicians, who call themselves HP3: Health Professionals for Patients in Pain, who have urged the agency to clarify the “misapplication” of its guidelines.” (See Health Professionals for Patients in Pain (HP3) )
In an April 10 reply, CDC Director Dr. Robert Redfield wrote that the agency was “working diligently to evaluate the impact” of the guidelines and “clarify its recommendations to help reduce unintended harms.”
This seems like a lie because if patient outcomes were being studied or at least counted, we would have heard about it by now, after so many suicides and so many people newly disabled and unable to work due to their untreated pain.
One former member of the CDC panel that established the guidelines, Dr. Lewis Nelson, said “it wasn’t just doctors who misinterpreted the guidelines. It was also regulators and legislators. Unfortunately, some must have just read the bullet points.”
The authors of influential federal guidelines for opioid prescriptions for chronic pain said that doctors and others in the health care system had wrongly implemented their recommendations and cut off patients who should have received pain medication.
It follows growing appeals from patient advocates, pain doctors, and some addiction experts for the CDC to clarify that its guidelines were just recommendations meant for patients suffering from chronic pain not tied to cancer, palliative care, or end-of-life care.
But in the new paper, the authors said that there were reports of them wrongly affecting care for other patients, including those with cancer or during acute sickle cell crises.
Andrew Joseph – Andrew is a general assignment reporter. – email@example.com – @DrewQJoseph
Ed Silverman – Pharmalot Columnist, Senior Writer – firstname.lastname@example.org – @Pharmalot