Were Consequences of CDC Guideline Unintended?

CDC Opioid Prescribing Guideline: Unintended Consequences? – July 2018 – an angry essay by yours truly, Angelika Byczkowski (Zyp Czyk)

I’m sick and tired of reading over and over how all the entirely predictable consequences of the CDC Opioid Prescribing Guideline were “unintended” and “unforeseeable”.

The broad misinterpretation of the guideline as establishing fixed limits on opioid prescribing has stranded hundreds of thousands of pain patients in agony without the effective relief they had achieved with opioids.

Yet we are expected to believe that these consequences were “unintended” and “unforeseeable” by the guideline authors. Most pain patients realized right away that the guideline’s suggestions would become codified rules, no matter how little evidence supported them.

And we were right – more than we ever imagined… 

Brain abnormalities are Consequence Not Cause of pain

Brain Gray Matter Decrease in Chronic Pain Is the Consequence and Not the Cause of Pain | Journal of Neuroscience – Nov 2009

If you can reverse brain “damage” by effectively treating the patient’s chronic pain, it seems pretty clear that the chronic pain was the cause.

This means we don’t have to accept the idea that abnormalities in our brains are what’s causing our pain (which some have hinted at).

Recently, local morphologic alterations of the brain in areas ascribable to the transmission of pain were reported in patients suffering from chronic pain.

Although some authors discussed these findings as damage or loss of brain gray matter, one of the key questions is whether these structural alterations in the cerebral pain-transmitting network precede or succeed the chronicity of pain.  

Pain Experts Call for End to Forced Opioid Tapering

International Stakeholder Community of Pain Experts and Leaders Call for an Urgent Action on Forced Opioid Tapering | Pain Medicine | Oxford Academic – 29 November 2018

We, the undersigned, stand as a unified community of stakeholders and key opinion leaders deeply concerned about forced opioid tapering in patients receiving long-term prescription opioid therapy for chronic pain.

This is a large-scale humanitarian issue.

As happy as I am to see this declaration, even long after the opioid prescribing guidelines were weaponized to force opioid tapers, I’m appalled that it took 2.5 years of entirely foreseeable consequences for all these doctors to finally speak up.

There’s an impressively long list of signatories to this document, including several that have been vocally pushing for the very restrictions they now call a “large-scale humanitarian issue”. I’m stunned at the hypocrisy.  

Low Risk of Opioid Use Disorder in Primary Care

Low Risk of Producing an Opioid Use Disorder in Primary Care by Prescribing Opioids to Prescreened Patients with Chronic Noncancer Pain | Pain Medicine | Oxford Academic – March 2017

This study shows what pain patients have been saying all along: prescribing opioids for patients with chronic pain very rarely causes problems of drug abuse.

Objective: 

To examine the risk of developing aberrant behaviors that might lead to a substance use disorder (addiction) when prescribing opioids for the relief of chronic noncancer pain in primary care settings.  

Some Inconvenient Truths About Opioid-War

The ‘Phony War’ Against Opioids: Some Inconvenient Truths | The Crime ReportThe Crime Report

Anyone who watches TV news will know that America has a major public health problem concerning drug addiction and opioid overdose deaths. In this context, we sometimes hear terms like “prescription opioid epidemic” and “over-prescribing” thrown about indiscriminately.

Hidden inside the hype and misinformation are several inconvenient truths. Public policy on the drug crisis cannot be remotely effective until we embrace such truths and act on them.  

Studies Show Addiction NOT Induced by Opioids for Pain

Introduction: Addiction and Brain Reward and Anti-Reward Pathways – free full-text article /PMC4549070/ – Aug 2011

This is a long and detailed article explaining at length how pain and addiction manifest in neurological processes in various areas of the brain.

It also contradicts the belief that opioids cause addiction, which has motivated the anti-opioid crusaders to make life a hell on earth for pain patients. (see Pain Patients Left to Suffer in ‘Hell on Earth)

Can One Induce Addiction
by Long-Term Treatment of Pain with Opiates? 

Crash Course for Submitting Comments to CMS

#HPM Crash Course in Submitting Comments to CMS | Matthew Cortland on Patreon – Feb 2018 – by Matthew Cortland

Mr. Cortland gives excellent advice for the best way to write your comments on opioid policy. Though his words are aimed at Hospice & Palliative Medicine (HPM) clinicians, I believe many of us chronic pain patients have just as much knowledge and experience with this subject.

CMS has published their proposed changes to Medicare for 2019.

Here are the changes that, in my view, may be the most concerning to Hospice & Palliative Medicine (HPM) clinicians:  

1. Starting to crack down on opioid ‘potentiator’ drugs – like gabapentin and pregabalin.
2. Limiting opioids to 90 MME per day.
3. Making it more difficult for patients to fill two or more long-acting opioids.   

DEA Raids Dr. Forest Tennant’s Pain Clinic

DEA Raids Dr. Forest Tennant’s Pain Clinic — Pain News Network  – November 16, 2017 By Pat Anson, Editor

Agents with the Drug Enforcement Administration have raided the offices and home of Dr. Forest Tennant, a prominent California pain physician, confiscating patient records, appointment books and financial documents.

In a lengthy search warrant, the DEA alleges that Tennant prescribed such high doses of opioid pain medication that his patients must be selling them.

So, the DEA got a search warrant based on their assumptions about his patients’ medical needs and their assumptions about what his patients are doing with their medication – no proof, no evidence, just assumptions. 

Opioid dose reductions have no effect on OUD rate

Prevalence of prescription opioid use disorder among chronic opioid therapy patients after health plan opioid dose and risk reduction initiatives. – PubMed – NCBI – August 2017

I found this evidence that opioid dose reductions are failing in their stated purpose of reducing the rate of Opioid Use Disorder (used to be addiction).

No studies have assessed the comparative effectiveness of guideline-recommended interventions to reduce risk of prescription opioid use disorder among chronic opioid therapy (COT) patients.

We compared the prevalence of prescription opioid use disorder among COT patients from intervention clinics that had implemented opioid dose and risk reduction initiatives for more than 4 years relative to control clinics that had not. 

Chronic Cancer versus Non-Cancer Pain

Chronic Cancer versus Non-Cancer Pain: A Distinction without a Difference? | GeriPal – Geriatrics and Palliative Care Blog – March 2016 – by Eric Widera, MD (@ewidera)

In 1824, Jeremy Bentham published the “Book of Fallacies” in which he criticized fifty arguments used in political debate and explained the sinister interests that led politicians to use them.

One of these fallacies he describes as the “sham distinction”, now known better as a “distinction without a difference“.

This logical fallacy appeals to a distinction between two two things that ultimately cannot be explained or defended in a meaningful way.