The US could see loosened guidance around prescribing opioids, as the US Centers for Disease Control and Prevention (CDC) considers relaxing some of its guidelines in a move that could signal a new direction for managing chronic pain.
The CDC last Thursday released proposed changes to its guidance on prescribing opioids, rolling back limits on which doses can be prescribed and for how many days in cases of acute pain.
The agency created rules in 2016 to reduce prescriptions that were fueling the opioid overdose epidemic. But as rules like these were put in place, opioid overdose deaths rose instead of falling.
New laws in several states were drafted to codify the restrictions, and some insurers began basing their coverage of medications on the guidance.
The sweeping actions cut off medications for some patients battling chronic pain and substance disorders, sometimes without the option of tapering down the medications or undergoing substance dependence treatment.
As the sources of medications dried up, some patients turned to illicit substances like heroin and fentanyl.
“You’re inadvertently driving people to an illicit supply if they’re being cut off,” said Kate Nicholson, executive director of the National Pain Advocacy Center. “The street supply is so tainted that you’re really pushing people to a very dangerous thing.”
Fatal overdoses rose from 63,000 in 2016 to more than 100,000 last year, many of them driven by the powerful synthetic opioid fentanyl. Deaths from fentanyl have doubled in the US in the past two years – but teens in particular have been hit hard by fentanyl overdoses, with the death rate tripling in that time.
Yet harm reduction groups have struggled to access affordable naloxone, the drug that reverses opioid overdoses. And only one state, Arizona, had enough naloxone in 2017 to prevent a majority of overdose deaths, according to a study published in the Lancet on Thursday.
‘It was being used against me’
For patients like Bev Schechtman, the 2016 CDC rules made what would have been a routine hospitalization traumatic.
Schechtman has Crohn’s disease, and frequently suffers from kidney stones – sometimes several times a month.
In 2017, a case of kidney stones grew too difficult to treat at home. She checked into the hospital because she was worried she was developing an infection and she was vomiting too much to keep food, water and prescribed painkillers down.
It was something she’d done several times before. But on this visit, Schechtman said, she was inexplicably denied intravenous painkillers because the doctor believed she was at higher risk of addiction since she had survived abuse as a child.
“He said, ‘Childhood sexual abuse changes your brain chemistry, and so do IV opioids, and so I can’t be part of that,’” Schechtman recalled.
She was floored – and horrified. “They’re using something that was already traumatic from my childhood, something that already is this painful experience that wasn’t my fault. And I felt like it was being used against me to punish me for – for what?”
That question nagged at her. When she was home and finally recovered, she started digging.
“Until then, I had no idea what the CDC guidelines were, I didn’t know any of this stuff,” Schechtman said. Since then, she has become an outspoken proponent of pain management and the vice-president of the non-profit Doctor Patient Forum.
She believes her experience happened because of an over-reliance on the stringent rules, and she applauded the new direction in guidance.
But the changes shouldn’t stop there, she said. “If these guidelines go through the way they are, then we have a lot of work ahead of us, because now we have to get them removed from state laws, we have to get them removed from the insurance companies.”
Caught in the pendulum swing
Drugmakers in the 1990s marketed new opioids as less addictive and pushed for wider use among patients.
“We overdid it with prescription medications – we were kind of sold a bill of goods by pharmaceutical companies that told us, no, these things are not addictive,” said Bryce Pardo, associate director of the Rand Corporation’s Drug Policy Research Center.
In reaction to the rising opioid overdose crisis, new rules in the late 2000s made it more difficult to prescribe the drugs – and around the same time, overdose deaths from illicit opioids began rising.
“We turned the tap off too quickly without really trying to increase the access to drug treatment programs,” Pardo said. Substance dependence treatment didn’t expand as quickly as patients needed.
“I think that’s what CDC is trying to do by relaxing some of the prescription guidelines now because they realize, well, we may have overdone it by trying to cut people off too quickly,” Pardo said.
But, he argued, the guidance shouldn’t go too far in the other direction: “We ping-pong back and forth between extremes.”
The new guidelines need to strike a delicate balance between making sure patients with serious pain have access to the medications they need, but also not introducing new patients unnecessarily to opioids, he said.
People in chronic pain can “manage their lives fine on an opioid – that’s fine. What we don’t want is a 19-year-old who blew out his knee at football practice getting 90 days’ worth of prescription medication.”
It’s difficult to reach that balance, said Nicholson, who called it “the Goldilocks solution”.
“There was a harm from overly liberal prescribing, so I do think the CDC stepped in in order to try and stem that harm,” she said. But “the people who actually needed it got caught in the crosshairs of this pendulum swing.”
She was on an advisory board to review an earlier draft of CDC guidelines last year. She said the new guidance, which incorporated the independent advisers’ feedback, is “a tremendous improvement for people with chronic pain”.
