Patients with chronic pain who need opioid treatment as a life-line have seen some very exciting developments within the span of just two weeks.
Quick backstory: Starting in 2016, many patients who were benefitting from opioids for the treatment of intractable pain were being told by their long-trusted doctors that their doses needed to be lowered dramatically or stopped altogether.
The doctors feared government scrutiny and eventual loss of license or other harsh penalties. As a result, patients were plunged into excruciating pain, and even suicide.
Along with doctors, insurers, health systems, regulators, and even pharmacists urged tapering or discontinuing opioids because, as the refrain went, "the government said so."
In reality, the government – that is, the Centers for Disease Control's 2016 Guideline for Prescribing Opioids for Chronic Pain -- said no such thing. Many health professionals did not know this, however.
So my colleagues and I formed HP3, Health Professionals for Patients in Pain, and on March 6 we sent an open letter to Dr. Robert Redfield, Director of the CDC. We pressed him to clarify that the agency’s otherwise reasonable Guideline did not mandate that doctors suddenly cut off or reduce the supply of opioid pain relievers to patients who were benefitting from them.
To his vast credit, the CDC responded on April 10. In a letter to us, Dr. Redfield wrote: “The Guideline does not endorse mandated or abrupt dose reduction or discontinuation, as these can result in patient harm… These practices can damage the clinician-patient relationship, and result in severe opioid withdrawal symptoms, including pain and psychological distress.”
We posted Dr. Redfield’s letter on the HP3 webpage and on social media so that patients could print it out and show their doctors.
On April 24, the CDC took another, even more significant, step by publishing a forceful and humane variant of the letter it sent to HP3 as an article in the New England Journal of Medicine. Now, thankfully, the agency’s robust clarification of the Guideline will have the widest audience possible.
The article’s authors, Deborah Dowell, MD, Tamara Haegerich, PhD, and Roger Chou MD — who also drafted the original 2016 Guideline — made their message unmistakably clear in a lead Perspective entitled, "No Shortcuts to Safer Opioid Prescribing."
The Guideline does not support policies or practices that mandate dose reduction or discontinuation, they explained, even though it does support individualized assessment of the potential value of tapering doses if the patient agrees to do so.
Crucially, they wrote:
Implementing recommendations with individual patients takes time and effort. An unintended consequence of expecting clinicians to mitigate risks of high-dose opioids is that rather than caring for patients receiving high dosages or engaging and supporting patients in efforts to taper their dosage, some clinicians may find it easier to refer or dismiss patients from care.
Clinicians might universally stop prescribing opioids, even in situations in which the benefits might outweigh their risks. Such actions disregard messages emphasized in the guideline that clinicians should not dismiss patients from care, which can adversely affect patient safety, could represent patient abandonment, and can result in missed opportunities to provide potentially lifesaving information and treatment.
My colleagues and I are enormously grateful to the CDC for these vital clarifications. But the work is not over.
We need to ensure that the CDC’s communication is translated into concrete policy by state and federal legislators, state medical boards, quality metric groups, insurers, pharmacy chains, and the Centers for Medicare and Medicaid.
Finally, some doctors are still intimidated by the Drug Enforcement Administration and will be reluctant to alter their prescribing habits, despite the CDC’s careful elucidations. Surveillance and enforcement procedures and protocols must be made transparent to physicians.
Responsible clinicians need sunlight, reassurance, and protections in order to prescribe medications that serve their patients well.
