Deaths from opioid overdoses have been surging. For years, the CDC has been concerned about the toll that opioid overdoses are taking. There have been reports that fentanyl and its chemical cousins are increasingly responsible for the dramatic increase in casualties (CDC Health Alert Network, July 11, 2018). Much of the fentanyl is counterfeit and is manufactured abroad. Headlines and soundbites on the evening news highlight the war on opioids but ignore the after-effects for people in pain. In an effort to reduce the deaths, the CDC issued guidelines with stringent caps on opioid prescribing in 2016.
Demonizing Opioids Injures People in Pain:
There is a downside to demonizing opioid pain medicines. Many chronic pain patients have been denied access to drugs like hydrocodone and oxycodone.
That’s because of pressure from the CDC, the DEA and insurers to discourage prescribing or dispensing of opioids. Many well-intentioned experts believe that overprescribing pain medicines led to opioid misuse and overdose deaths. In 2016 the agency issued very stringent guidelines to limit prescriptions for narcotics. This was an effort to reduce abuse or misuse of these powerful compounds.
The impact of the guidelines was substantial. Doctors were a lot more cautious about prescribing drugs such as hydrocodone, methadone, morphine or oxycodone after the CDC’s recommendations came out.
The message was that opioids should be used only for acute pain such as after a serious accident or surgical procedure. Health professionals were told that prescribing these drugs wouldn’t help patients in chronic pain. But most patients were not offered alternatives.
Those CDC Guidelines Went Too Far and Hurt People in Pain:
As we suggest above, the CDC initial reaction to this public health threat was extreme. It urged doctors to limit the amount of opioids they prescribed regardless of the degree of pain their patients were in.
Unfortunately, in addressing the harms of opioid use, the agency may have overlooked the impact on people in pain. We heard from hundreds of patients who had their pain medication abruptly discontinued.
One woman wrote:
“I have arthritis, degenerative bone disease, peripheral neuropathy and spinal stenosis. Back surgery worsened the pain, and I have needed more than twenty other surgeries.
“I was doing well with oxycodone and fentanyl patches. Then I went to my doctor for a checkup and was taken off these medicines cold turkey. I had never taken more than I was prescribed, but I was not given a replacement.
“Now my muscle relaxant has been cut back to 5 mg a day, along with gabapentin. As we get older, doctors don’t seem to care about us. I now need a walker to get around. Are we just supposed to die from pain?”
Another reader raised a different issue:
“I have chronic back pain. At age 89, under my doctors’ guidance, I have tried a range of treatments from surgery to Tylenol. This list includes hydrocodone, which provides several hours of relief.
“Some time back I required four to five tablets per day. Now I am down to one or two, and they don’t provide nearly the same degree of relief.
“I have used hydrocodone responsibly, under the guidance of a physician. Those of us who have used these important pain reducers may end up seeking relief through suicide or obtaining narcotics from an illegal source. This will only make the abuse problem worse.”
New CDC Guidelines May Be More Compassionate:
The CDC is revising its guidelines for opioid prescribing. This public health agency has now recognized that cutting people off from their pain medicines has led to a lot of unintended consequences. The new recommendations will encourage health care providers to individualize pain management plans. They will also permit prescribers to use their own best judgment when determining dosage (CDC Feb, 10, 2022).
That said, the CDC is not opening the flood gates to routine narcotic prescribing.
It still reminds doctors that
“opioids should not be considered first-line or routine therapy for subacute or chronic pain.”
Instead, the agency is encouraging clinicians to begin with non-drug approaches such as physical therapy, acupuncture, heat therapy or supervised exercise. Non-narcotic pain relievers such as ibuprofen, acetaminophen or gabapentin are recommended as substitutes.
There is a new appreciation, though, that such measures won’t work for everyone. Some people have experienced a botched surgery or traumatic injury that leaves them in constant pain. Others have complex pain syndromes that are extremely difficult to treat.
Giving doctors leeway to help each patient find the best combination of approaches to alleviate their distress is far more humane.
The FDA Listened to Patients in Pain:
Back in 2018, the Food and Drug Administration held hearings, and patients in chronic pain voiced their frustrations (FDA Meeting on July 9, 2018). You can watch the videos of the:
Morning Session at this link
Afternoon Session at this link
The Other Opioid Crisis for People in Pain:
Many people in pain complained at the FDA meeting that the medications that helped them function previously were being withheld, even if they took them precisely as prescribed.
One patient who testified at the FDA hearings was a disabled registered nurse with cervical scoliosis and ruptured disks that cause unremitting pain. She had been treated for a decade, going to the pain clinic each month and seeing her primary care physician every three months. Although she never was identified as a problem patient, she was suddenly unable to access the pain medicine that allows her to function.
The Government Made Opioid Access Challenging:
Many doctors were intimidated by government restrictions on opioid prescriptions. The CDC had issued guidelines that discouraged the prescribing of opioids for chronic pain patients (March 18, 2016). Patients in severe pain often felt as if they are being treated like drug abusers or criminals.
That’s because of this CDC recommendation to physicians:
“When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.”
We have heard from hundreds of people in pain who are desperate as a result of these restrictions.
One person wrote:
“I have more than I can handle just typing right now. The pain meds don’t make it so I can walk. At times, I even try not to drink anything for fear that I might have to go to the bathroom.
“If the restrictions get even tighter, I won’t be able to tolerate it. I only tolerate it now so I don’t leave my golden retriever alone. He’s the reason I haven’t killed myself already.”
Another man wrote:
“I had back fusion surgery involving multiple vertebrae. It left me worse than before. I’ve been on [opioid] pain meds for five years, with a drug test every month, and I have never caused any problems.
“Now the doctors are cutting my meds so much that my quality of life is zero. It was bad enough before. I am considering suicide and I wonder if that is what they want.”
Erin in Reno Nevada shares this story:
“I have been looking for nearly a year now for a doctor to help me with my chronic pain. Because of the limitations that the DEA and now the state has put on doctors, the majority do not want to prescribe opioids.
“I moved from California to Nevada for retirement. I am having to drive to California to my doctor there to get my prescriptions because no doctor wants to prescribe what I need to control the chronic pain I live with 24/7.
“It’s horrible how the doctors and the DEA are treating patients in pain. We are just trying to live a normal life. Even though we get our meds the right way and do not abuse them, we are treated as if we are drug addicts. It is sooo unfair.”
Jeff is considering suicide:
“I’ve had 381 total surgeries. I’ve always done the right thing, whatever the doctor has told me. I have never taken more medicine than I was supposed to. Now they look at a computer and say we have to cut your meds since the computer says so.
“I use ice, constant getting into a tub of ice. It’s great for a few minutes. The only option I can come up with is to now drink enough alcohol and see if that helps. IF that won’t help then I’ll be looking face first down the end of a gun barrel. I can’t stand it and I’m not living in an ER any longer.
“People who have abused the medicine have made it terrible for the ones that need it. My life will have to end without any help.”
What About Cancer Patients?
Even cancer patients were not immune to the increasing restrictions:
“My father attempted suicide last week because the director of his pain clinic abruptly cut all his pain meds. He suffers irreversible chronic cancer pain!”
Not every person in chronic pain is considering suicide. But they all deserve compassionate treatment to alleviate their agony.
Read more stories at this link. Over 700 people have shared their experiences here.
Where are the Alternatives to Opioids?
Opioids have been used for more than 5,000 years. They are powerful analgesics. Until drug companies develop more effective and safer alternatives, decision makers need to recognize that people with intractable pain deserve relief. For some, that will require opioids.
Keeping illicit fentanyl and its derivatives out of the country might be a more productive way to control the opioid epidemic that is killing people.
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