Pain Specialists Denounce CDC Opioid Guidelines

Pain Specialists Pile on CDC Opioid Guidelines | MedPage Today – by Elizabeth Hlavinka, Staff Writer – Sept 2019

It’s infuriating that three solid years of professional medical criticism, even from some of the people involved in the original writing, hasn’t resulted in the withdrawal or “rewriting” of the CDC guideline.

In the 3 years since the guidelines were published, at least 33 states have enacted legislation that limits opioid prescribing, and although half of these states specify that the new limits are intended for patients with acute pain, many physicians have stopped prescribing opioids to chronic pain patients as well, according to Gary Jay, MD, of the University of North Carolina in Chapel Hill.

In April, the authors of the guidelines stated that the recommendations were not intended to force hard limits of opioid doses, abruptly taper or stop opioid use, or be applied to patients outside the guidelines’ scope, such as patients undergoing active cancer treatment or, in some cases, patients with chronic pain.  

FDA’s 2019 policy and regulatory agenda

Statement from FDA Commissioner Scott Gottlieb, M.D. on the agency’s 2019 policy and regulatory agenda for continued action to forcefully address the tragic epidemic of opioid abuse – from FDA.gov – Feb 2019

I believe this is Mr. Gottlieb’s goodbye to go along with his resignation.

The opioid crisis is one of the largest and most complex public health tragedies that our nation has ever faced. It remains the biggest public health crisis facing the FDA.

The toll of addiction, in lost lives and broken families, touches every community in America. Sadly, the scope of the epidemic reflects many past mistakes and many parties who missed opportunities to stem the crisis, including the FDA.

I’m surprised that he admits right off the bat that this crisis could have been mitigated if they had acted sooner, though not in the manner he imagines. 

Opioid taper as an institutional mandate

Opioid discontinuation as an institutional mandate: Questions and answers on why we wrote to the Centers for Disease Control and Prevention: Substance Abuse: Vol 40, No 1 – Stefan Kertesz, MD – May 2019

This article explains what the HP3 group wanted to accomplish with their letter “protesting” the CDC guideline. It looks like it worked!

On March 6, 2019, a self-designated committee (Health Professionals for Patients in Pain, HP3, a group that is not incorporated and accepts no contributions) sent a public letter to the Centers for Disease Control and Prevention (CDC), urging the agency to address the widespread misapplication of its 2016 guideline on prescribing opioids.

318 health care professionals and three former directors of the White House Office of National Drug Control Policy (“Drug Czars”) signed the letter, as did the parent organization for Substance Abuse, the Association for Multidisciplinary Education and Research on Substance use and Addiction.  

FDA warns against sudden discontinuation of opioids

FDA identifies sudden discontinuation of opioid pain medicines – fda.gov – Apr 2019

I don’t know how I missed this until now. If your doctor is trying to force you into a taper, you can let them know that the FDA warns against taking opioids away from pain patients without a medical reason and then only in a carefully planned extremely gradual taper.

The U.S. Food and Drug Administration (FDA) has received reports of  serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased.

These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.   

CDC Joins FDA in Decrying ‘Mandated Dose Reduction’

Seeking to Clarify Its Opioid Prescribing Guidelines, CDC Joins FDA in Decrying ‘Mandated or Abrupt Dose Reduction’– by Jacob Sullum – Apr 2019

Acknowledging the suffering caused by “misinterpretation” of the opioid prescribing guidelines it published in 2016, the U.S. Centers for Disease Control and Prevention (CDC) yesterday sought to clarify that it never recommended imposing involuntary dose reductions on chronic pain patients.

In a letter to physicians who had objected to that widespread practice, CDC Director Robert Redfield emphasized that his agency “does not endorse mandated or abrupt dose reduction or discontinuation, as these actions can result in patient harm.”

The CDC may not “endorse” them, but they deliberately looked the other way for 3 years while this was happening. 

Too Little, Too Late: Feds Backtrack on Opioid Discontinuation

Too Little, Too Late: US Government Backtracks on Opioid Discontinuation

Thousands of patients have been dispassionately forced into tapering their opioids, often inappropriately, due to fear from regulatory agencies following initiation of the 2016 CDC Guideline on Prescribing Opioids for Chronic Pain.

In addition to unnecessary suffering, this has resulted in opioid withdrawal due to due either rapid or misguided or inexperienced taper regimens.

The sad irony here is that three years later, the FDA is saying exactly what nationally recognized pain experts have been saying all along.  

FDA identifies harm from discontinuation of opioids

Drug Safety and Availability > FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering

The U.S. Food and Drug Administration (FDA) has received reports of serious harm in patients who are physically dependent on opioid pain medicines suddenly having these medicines discontinued or the dose rapidly decreased. These include serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide.

It’s strange to read this acknowledgment of “harms” from forced tapers after three full years of seeing these “harms” implemented very deliberately as a consequence of the disastrous CDC opioid prescribing guideline.

While we continue to track this safety concern as part of our ongoing monitoring of risks associated with opioid pain medicines, we are requiring changes to the prescribing information for these medicines that are intended for use in the outpatient setting.

“We continue to track this safety concern” implies they’ve been doing this all along, which they have not. 

MedWatch Voluntary Reporting Form

MedWatch Voluntary Reporting Form – the official FDA site for complaints

Another patient described on Pharmacist Steve’s blog how to word complaints about sudden, medically unjustified, reduction in opioid medication:

Here’s the blurb I came up with:

Withdrawal symptoms, and other adverse reactions, are considered a serious safety problem with medication, especially when this is happening as a result of a doctor abruptly discontinuing or inappropriately tapering your drug treatment in a way directed against in the medicine’s US FDA approved prescribing information.  

How the Fed Used Opioids as Scapegoat

Games without Frontiers: How the Fed Used Opioids as Scapegoat & Diversion for the Nation’s True Crises – by Matthew Giarmo, Ph.D. – Sept 2018

Here’s a guy who lays it out as he sees it, remarkably similar to the view of pain patients. This could be because he took time off to take care of a family member with cancer – he saw firsthand the full destructive force of their pain.

EXECUTIVE SUMMARY

• The problem is not opioids. It’s heroin.
• The problem is not painkillers. It’s pain.
• The problem is not prescription. It’s diversion.

To all those sanctimonious crusaders, self-aggrandizing careerists, and shameless opportunists looking for a piece of the opioid pie, I say that you are more addicted to the opioid crisis than we are to opioids. 

Report adverse or no medication effects to the FDA

MedWatch Voluntary Reporting Form – for reporting adverse drug effects to the FDA

Perhaps the FDA doesn’t know how ineffective “alternative” non-opioid drugs are for pain because no one has told them. You can download a form from this site (link above) to report your experiences.

Use the MedWatch form to report adverse events that you observe or suspect for human medical products,including

• serious drug side effects,
• product use/medication error,
• product quality problems, and
• therapeutic failures

It’s this last category that presents our opportunity for action. We could report the “therapeutic failures” and awful side-effects of non-opioid medicaitons like Lyrica, gabapentin, or antidepressants for pain.