On March 10, 2020, the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic hosted a 90 minute “listening session” to “better understand the experiences and perspectives of clinicians caring for patients with chronic, non-cancer pain.” This was the second of two such sessions (the first was conducted with a selected panel of patients). In both sessions, my overall impression is that NAM seems to be “stacking the deck” to lend support to the CDC Guidelines – essentially ignoring or marginalizing the enormous damage that these guidelines have done to patients, caregivers, and doctors. This is not a useful basis for policy.
The audio of the listening session will be made available online in the coming days. In the meantime, I have submitted the following commentary via an online form provided by the NAM Action Collaborative.
What successes have you had in providing care to patients with chronic pain?
Having listened to the comments of the medical professional panelists who participated in the NAM panel discussion, I cannot escape the impression that to some degree these participants seem to have been pre-filtered or hand-picked to represent points of view that are in many particulars wildly at variance to the lived experience of their patients. While some panelists alluded to the sharp differences in perception between doctors and patients, the causes of this divergence were largely unexamined or ignored.
It is fundamentally wrong and unethical to ascribe “drug seeking behaviors” to patients as a whole, whether inferred from patient misunderstanding or as an implied behavior of people addicted to opioid medications. As no less an authority than Dr Nora Volkow (Director of NIDA) tells us in NEJM, “addiction is not a predictable outcome of medical prescribing.” This principle seemed to be neatly set aside in the “listening” session.
Particularly vexing to a patient advocate like me was the prevailing opinion that despite “unintended consequences” or “mis-application” of the 2016 CDC opioid guidelines, the impact of that fatally flawed document was viewed as a “success”. The implicit assumption was made that mandated reduction of overall levels of opioid prescribing represents a “success” for medical practice overall. Also frustrating to patients was the assumption that “over-prescribing” is a significant cause of our present US opioid “crisis”. There is ample published medical evidence to disprove both premises.
Also of concern is casual acceptance of the deeply flawed assumption that co-prescription of benzodiazepine drugs and opioids is inherently dangerous. Benzodiazepines are an essential element of treatment for anxiety and depression. There are also no published trials establishing any threshold of effects in respiratory depression among live patients; all papers in this field are based on postmortem statistics.
See “Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality “, Dasgupta et al, Pain Medicine, Volume 17, Issue 1, January 2016, Pages 85–98, https://doi.org/10.1111/pme.12907
What challenges have you had in providing care to patients with chronic pain?
The observations of the panelists with regard to challenges of current practice have some validity. Changes in State and Federal regulations and guidelines, insurance reimbursement and chain pharmacy prescribing policy have introduced great turbulence and burdensome paperwork into the profession. While law enforcement and State Medical Board threats to doctor licenses and prosecutions were mentioned tangentially, the full impact of these threats on patients was not adequately discussed. Hundreds of thousands of both legacy and new patients cannot now find a doctor who will treat their pain with the only means that are effective for many of them as individuals: opioid pain relievers. Doctors are running scared, and many of their patients are being deserted.
How have prescribing guidelines for prescribing/dispensing medications/opioids for chronic pain positively impacted the people in your care?
Panelist attention seemed to be focused on improvements in the coordination of multiple modalities of patient care. Also suggested was the idea that by making terms of treatment explicit, communications between doctor and patient should be improved, and patient expectations better managed. Missing in the discussion was any reference to the substantial body of published medical evidence that many of the therapy techniques recommended as alternatives to protracted use of opioids simply don’t work for the great majority of patients — and even when they do work, they offer only temporary improvements at the margins of treatment by analgesics and anti-inflammatory drugs. See the systematic outcomes review for non-invasive, non-pharmacological pain treatments, published in June 2018 by AHRQ.
Likewise mostly not addressed is the reality that ever more burdensome paperwork and reporting requirements are creating disincentives to treat patients, and driving more doctors out of pain management practice.
How have prescribing guidelines for prescribing/dispensing medications/opioids for chronic pain negatively impacted the people in your care?
Some consideration was given by panelists to the negative impacts of guidelines on patients. But the nature of these impacts was for the most part attributed to “misapplication” of the guidelines, not to errors of fact and science that are now well established.
- Properly supervised opioid therapy is both safe and effective for the great majority of patients.
- In the most recently released CDC analysis of prescribing data, there is no correlation between rates of opioid prescribing and rates of opioid addiction or overdose mortality.
- The AMA has repudiated Morphine Milligram Equivalent Dose (MMED) as a basis for care planning and risk assessment. Many patients benefit from doses well above the 50/90 MMED thresholds identified by CDC.
- No presently available patient profiling instrument has useful predictive accuracy in flagging patients at elevated risk of either substance abuse disorder or mortality. (see “Opioid Treatments in Chronic Pain”, AHRQ report draft circulated October 2019). HHS criteria for “Excessive Utilizers” also have limited predictive accuracy in flagging patients at elevated risk of either substance abuse disorder or mortality.
- The final report of the 2019 HHS Pain Management Task Force states that there is no one-size-fits-all patient or treatment plan. One underlying reason for this reality is that the natural variability of human metabolism creates a very wide range of minimum effective dose levels due to genetic polymorphism in liver enzymes. Some patients need only minimal amounts (~20 mmed) to obtain pain relief; others may require doses that would knock over a horse (~1000 mmed or higher).
If you had a “magic wand”, what would you change in the health system to improve care for patients with chronic pain?
If I had a magic wand, the CDC would be directed to withdraw and disclaim the 2016 guidelines on opioid prescribing, on grounds of errors in fact and failure to communicate appropriate protections for both legacy and new patients. Any replacement document should implement AMA House of Delegates Resolution 235 (November 2018) and Board of Directors Study 22 (June 2019) as central principles of National pain care policy.
The core principle in opioid prescribing for chronic pain must again become titration to desired effects in the individual patient, while monitoring for and managing untoward side effects. Drug dependence is a consequence of long term treatment at high doses, and should never be confused with addiction. Absent some indication of actual and quantifiable patient harms, forced (involuntary) tapering of opioids that have been beneficial to the patient in the past, should not be attempted. There are presently no published trials demonstrating benefits from mandated tapers. In the absence of effective alternatives to opioids, mandated tapers are irresponsible, dangerous, and medically unethical.