One-Size-Fits-All Regulations Can Be a Straitjacket

Governors Discover One-Size-Fits-All Regulations Can Be a Straitjacket—The Same Is True With Pain Prescription Limits | Cato @ Liberty – By Jeffrey A. Singer – Mar 2020

The 2016 guidelines for the treatment of acute and chronic pain issued by the Centers for Disease Control and Prevention, like Medicare’s CRNA regulation, were always meant to be optional. In fact, in its opening section, the guidelines state:

“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context.”

This is the part that everyone is ignoring but will come back to haunt us when more and more of medicine is standardized. This COVID crisis is exposing how disorganized and broken (but always profitable!) our healthcare system is. 

The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations.

Clinicians should consider the circumstances and unique needs of each patient when providing care.

That didn’t stop governors and state legislatures from enacting strict restrictions on opioid prescribing by health care practitioners. The majority of states have statutory limits on the dosage and quantity of opioids a provider can prescribe to a patient in pain

These constraints were enacted despite major criticism from medical professionals and the American Medical Association that the CDC guidelines lack a strong basis in the evidence.

April 2019, the CDC issued a clarification of the 2016 guidelines, claiming these guidelines were misinterpreted and misapplied…

I don’t think they were “misinterpreted and misapplied”. I think anti-opioid zealots were just waiting for specific dose numbers to start enacting global restrictions on opioid medication. See Were Consequences of CDC Guideline Unintended?

…and two of the guidelines’ authors wrote in the New England Journal of Medicine:

We need better evidence in order to evaluate the benefits and harms of clinical decisions regarding opioid prescribing, including when and how to reduce high‐​dose opioids in patients receiving them long term. The CDC developed the guideline on the basis of the best available evidence, with input from a multidisciplinary group that included experts in pain management as well as representatives of patients and the public. In situations for which the evidence is limited, it is particularly important not to extend implementation beyond the guideline’s statements and intent. And yet in some cases, the guideline has been misimplemented in this way.

In May 2019, the Department of Health and Human Services released a report from its Pain Management Best Practices Inter‐​Agency Task Force. The report stated in its Executive Summary:

The Task Force recognizes the utility of the 2016 Guideline for Prescribing Opioids for Chronic Pain released by the CDC

also recognizes unintended consequences that have resulted following the release of the guidelines in 2016, which are due in part to misapplication or misinterpretation of the guideline, including forced tapers and patient abandonment.

Among its conclusions:

An emphasis on an individualized, patient‐​centered approach for diagnosis and treatment of pain is essential to establishing a therapeutic alliance between patient and clinician…

Nevertheless, state‐​based restrictions remain in place, straitjacketing health care practitioners who want to relieve their patients’ pain.

The COVID-19 pandemic provides many lessons for policymakers. Many lessons reveal how complicated, inflexible, one‐​size‐​fits‐​all regulations stifle swift and effective responses to changing circumstances.

Hopefully this experience will cause state leaders to free clinicians to exercise their best judgment in treating their patients in pain once again.