By Pat Anson, PNN Editor

Over 5,000 healthcare providers, patients, caretakers and advocacy organizations have left comments in the Federal Register on a draft report by a federal advisory panel known as the Pain Management Best Practices Inter-Agency Task Force. The comment period ended April 1.

Most of the comments – which you can see by clicking here – are supportive of the report, which recommends that pain management be balanced, multimodal and focused on individualized patient care. Opioid pain medication should be prescribed cautiously, if prescribed at all, according to the task force.

Those may sound like reasonable and prudent goals, but one aspect of the draft report has stirred controversy and it’s a familiar one: the CDC’s 2016 opioid prescribing guideline.

While commending its “useful general guidance,” the report found that that guideline has had many unintended consequences, including forced opioid tapering, patient abandonment and suicide. The task force said the guideline was never meant to be mandatory or to be used as a model by states, insurers and pharmacies, and better evidence was needed to support its recommendations.

The task force stopped short of recommending a wholesale revision of the guideline, but suggested a “more even-handed approach” to pain care was needed.  

“In essence, clinicians should be able to use their clinical judgement to determine opioid duration for their patients,” the report concludes.

Those were fighting words to some anti-opioid crusaders and politicians who consider the CDC guideline a cornerstone of the government’s war on drugs.

“As a matter of public safety, there is simply no justification to move away from the CDC Guideline to encourage more liberal use of an ineffective treatment that causes nearly 50,000 deaths annually,” warns a letter signed by 39 state and territory attorney generals.  “It is incomprehensible that officials would consider moving away from key components of the CDC Guideline.”

‘They Have Overreached’

The AG’s letter shows a fundamental and perhaps willful ignorance of what the guideline is – a voluntary set of recommendations intended only for primary care physicians. The letter also demonstrates how politicians have grown accustomed to inserting themselves into pain management decisions normally left between patients and their doctors. In essence, the AG’s are saying that doctors should not be allowed to use their own clinical judgement and should rely instead on treatment guidelines.  

“The Draft Report proposes to rely solely on the judgment of providers regarding the dose and duration of opioid treatment. With annual overdose deaths in the tens of thousands, evidence-based recommendations, such as documentation and consultation, are necessary,” the AG letter states. “Similarly, the Draft Report states that duration of opioid treatment for acute pain, including trauma and surgery, is best determined by providers without the need for guidelines to inform appropriate decision-making.”

Critics say the AG’s are essentially practicing medicine without a license.

“The foxes watching the hen house want more hens to watch, more justification for their existence,” says Mark Ibsen, MD, a Montana doctor all too familiar with government intrusion into pain care. Ibsen’s medical license was suspended in 2016 over allegations that he overprescribed opioids, a decision later reversed by a judge.

“They have overreached. I hope someone else notices, and takes law enforcement out of the practice of medicine, where they’ve been screwing up medical care since 1914. Abolish the DEA. Let law enforcement catch criminals, not make them up out of thin air,” Ibsen said.

This isn’t the first time the National Association of Attorneys General has tried to meddle in pain care. In 2017, the organization sent a letter to health insurers asking them to take steps to reduce the prescribing of opioid medication.

“Reducing the frequency with which opioids are prescribed will not leave patients without effective pain management options,” the 2017 letter states. “When patients seek treatment for any of the myriad conditions that cause chronic pain, doctors should be encouraged to explore and prescribe effective non-opioid alternatives, ranging from non-opioid medications (such as NSAIDs) to physical therapy, acupuncture, massage, and chiropractic care.”

In their latest letter, it’s no longer a matter of “should.” The AG’s say doctors “must be encouraged” to reduce opioid prescriptions and to recognize that opioids have “well established risks.”  

“The Draft Report should be revised to clearly state that there is no completely safe opioid dose, and that higher doses are particularly – and predictably – risky,” the AG’s wrote.

But most opioid medications are not particularly risky, as PNN reported in a recent study of over half a million Medicare patients who were prescribed the drugs. Over 90 percent had a negligible risk of an overdose. Even among “high risk” patients on high opioid doses, the risk of an overdose is less than two percent.

‘Too Much Money On the Line’

Critics also point out the AG’s have a political and financial interest in demonizing opioid medication. Most have signed on as plaintiffs in over 1,600 class action lawsuits filed by states, cities and counties seeking billions of dollars in damages from opioid manufacturers and distributors. Oklahoma Attorney General Mike Hunter – one of the AG’s who signed the letter criticizing the task force report --  recently reached an out-of-court settlement with Purdue Pharma for $270 million.  

“There is just too much potential money on the line. This is not an argument about truth, or evidence, or anything except money," says Andrea Anderson, Executive Director of the Alliance for the Treatment of Intractable Pain (ATIP).  

“Since the Purdue/Oklahoma settlement of $270 million, all the AG’s of every state involved in this opioid litigation will focus solely on their potential financial gains until they get their piece of settlement pie. This will come at the cost of needed revisions to the flawed CDC Guidelines and a return to clinical common sense. People can remember these AG’s when they vote.” 

According to OpenSecrets.org, the law firm of Simmons Hanly Conroy donated over $1 million to congressional candidates during the 2018 election cycle. Simmons Hanly Conroy represents dozens of states and local governments that are suing drug makers over their marketing of opioids, and would pocket one-third of the proceeds from any settlements, according to reports.

A recent PNN survey found the CDC guideline was having a harmful effect on both patients and healthcare providers. Over 85 percent of patients say the guideline has made their pain and quality of life worse. Nearly half have considered suicide. Over two-thirds of practitioners are worried about being sanctioned or prosecuted for prescribing opioids. Rather than risk going to prison, many have stopped treating pain, closed their practice or retired.