A Light at the End of the Tunnel for People in Chronic Pain

Drastically tapering opioids in some patients can lead to intense suffering and even suicide
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In a somewhat startling policy reversal, the U.S. Department of Health and Human Services has issued new guidelines for opioid prescribing for doctors treating people in chronic pain. The guidelines caution prescribers that abruptly tapering or discontinuing opioids in this population can lead to serious harms, including severe depression, thoughts of suicide, and the use of illicit drugs to control pain and symptoms of withdrawal.

Issued Oct. 10, 2019, the new guidelines urge physicians to treat people in pain as individuals rather than adhering to a rigid set of prescribing guidelines. “We need to treat  people with compassion,” said Adm. Brett P. Giroir, M.D., assistant secretary for health, in a statement issued by HHS. The statement also emphasized the need for shared decision making between patient and physician and balancing the risk of addiction with the patient’s ongoing need for pain control.

Chronic pain affects about 20 percent of all adults living in the United States. About 8 percent of those people suffer from what the CDC terms “high-impact pain”  — pain that limits life or work activities on most days or every day. People over 65, people who live in poverty and those who live in rural, underserved communities are more likely to suffer from both chronic pain and high-impact chronic pain.  

A Departure from Recent Policy

The new guidelines are a sharp departure from those issued by the U.S. Centers for Disease Control and Prevention in 2016, which many doctors and policymakers took to be a mandate to limit opioid prescribing “or else.” Those guidelines emphasized the need to evaluate the “risks and benefits” of opioids for every patient and set an upper limit on the dose of opioids chronic pain patients should receive. Doctors were encouraged to use non-pharmaceutical pain management modalities for their chronic pain patients —  an idea that has faced numerous roadblocks, most importantly access and cost. 

The fallout from the CDC guidelines  — issued in the midst of an unprecedented epidemic of opioid-related deaths — was both predictable and swift. Doctors began severely curtailing the number of pain pills they prescribed for patients in acute pain and cutting the opioid dosage for patients who had been maintained on high-dose opioids for years. Then the states stepped in, issuing their own regulatory guidance on the doses of opioids doctors could prescribe. Insurers and pharmacies soon followed suit, setting their own arbitrary policies about how opioids could be dispensed. 

The CDC guidelines left many doctors thinking they had no choice but to taper their patients off long-term opioids
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In the wake of this regulatory tsunami, millions of chronic pain patients saw their pain destabilized and their lives turned upside down. Even people with cancer and other life-limiting illnesses found themselves unable to fill prescriptions for opioids they had been taking for years.

Prescribing Guidelines “Misapplied,” CDC Says

Now, in the wake of aggressive pushback from pain patients and advocates from across the globe, the authors of those CDC guidelines say they were “misapplied.” In a paper published this March in the New England Journal of Medicine, they admit that little is known about “the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them” and blame a variety of stakeholders for taking their guidance too far. While defending the intent of the initial guidelines, they simultaneously urged policymakers to “allow clinicians to account for each patient’s unique circumstances in making clinical decisions,”  — a sharp departure from the tone of the guidelines issued just three years ago. 

A Much Needed Correction

Although opioid overprescribing undoubtedly contributed to the epidemic of opioid deaths still plaguing the United States, it’s now clear that the CDC’s guidance created as many problems as it solved. The number of opioid prescriptions written in the country and deaths from prescription opioids has declined. But deaths from illicitly manufactured fentanyl, a synthetic opioid 50 to 100 times more powerful than morphine, rose nearly 50 percent between 2016 and 2017. And while it’s impossible to know for sure, some of those who died were undoubtedly people who turned to illicit drugs when their access to the prescription medicine on which they depended was cut off. 

New opioid prescribing guidelines may make it easier for patients in pain to get needed medicines
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In a statement published in the journal Pain Medicine in November 2018, an eminent panel of physicians and stakeholders condemned the aggressive tapering of opioids for patients on long-term, high-dose opioids for chronic pain. A scathing indictment of rigid policies that have left physicians no choice but to harm patients they had sworn to help, the statement cites an “alarming increase in reports of patient suffering and suicides within and outside of the Veterans Affairs Healthcare System in the United States.” The authors called on the Department of Health and Human Services to perform an “urgent review of mandated opioid tapering policies for outpatients at every level of health care” and adopt immediately strategies to mitigate the risk of patient harms. 

It would appear that last week’s policy pivot may be the first step towards achieving that goal. For the millions of Americans struggling with chronic pain, it comes not a moment too soon.