AARP Should Stop Blaming Pain Patients for the Opioid Crisis

By Carol Levy

Toast and jam. Cake and coffee. Peanut butter and jelly. Pain patients and the opioid crisis.

One of these things is not like the others. But to most people, they all go together. Even when research shows little correlation between opioid prescriptions and overdose deaths.

We’ve been hearing that same old tired narrative for years, often from “experts” who speak with absolute certainty.

“Two major facts can no longer be questioned. First, opioid analgesics are widely diverted and improperly used, and the widespread use of the drugs has resulted in a national epidemic of opioid overdose deaths and addictions,” Nora Volkow, MD, Director of the National Institute on Drug Abuse, and Thomas McLellan, PhD, founder of the Treatment Research Institute and a scientific advisor to Shatterproof, wrote in a joint op/ed in The New England Journal of Medicine in 2016.

“Second, the major source of diverted opioids is physician prescriptions. For these reasons, physicians and medical associations have begun questioning prescribing practices for opioids, particularly as they relate to the management of chronic pain.”

We now know that prescription opioids play a minor role in the overdose crisis and that only about three-tenths of 1% are actually diverted. Illicit fentanyl and other street drugs are responsible for the vast majority of overdose deaths, not pain medication.

But the same tired and misinformed narrative continues, with patients who need opioids paying the price when their doses are reduced or taken away.

Recently, the American Association of Retired Persons released an AARP bulletin, with the main headline being “The War on Chronic Pain.” Wow!  I was excited. Maybe some new information that I can use?

My heart sank as I read the article and quickly came upon these words: “Our attempts to treat chronic pain with medication have led to an opioid abuse epidemic so severe that overdoses are now among the leading causes of death for adults ages 50 to 70. “

The stereotype wins again. Prescription opioids caused the crisis.

I was curious to see what else AARP had to say about pain management and found several articles over the years with a glaringly obvious bias against opioids.

“Americans over 50 are using narcotic pain pills in surprisingly high numbers, and many are becoming addicted,” a 2017 AARP article warned. “A well-meant treatment for knee surgery or chronic back troubles is often the path to a deadly outcome.”

The article went on to claim that older Americans had become “new opioid dealers” who fueled the opioid crisis by “selling their prescription painkillers to drug pushers.”

A 2019 AARP article took a more nuanced approach to pain, claiming that “science was homing in on better ways to treat it,” such as non-opioid drugs, exercise and cognitive therapy.

“If the opioid crisis has provided an excellent example of how not to treat chronic pain, advances in brain science are leading to a fuller understanding of how to more safely find solutions,” AARP said.

Five years later, science has brought us no real solutions. Opioids are still the most potent and reliable medications for pain. For patients in severe pain, they are often the only treatment that works.

The sad part is, if AARP had simply asked the American Medical Association, they would have found that prescription opioids are not the main cause of overdoses and deaths.

In 2021, the AMA reported that opioid prescriptions had fallen by over 44%, yet drug overdoses and deaths were still rising. “The nation’s drug overdose and death epidemic has never just been about prescription opioids,” said then-AMA President Gerald Harmon, MD.

In a 2023 report, the AMA warned again that “reductions in opioid prescribing have not led to reductions in drug-related mortality.”

Why is that not worth including in AARP’s latest sensational reporting on the opioid crisis?

I read this line the other day: “There is no word for infinite pain.” That rings very true for me, probably for many of us. Chronic pain often does not end. We may have a diagnosis, some condition or disorder that causes pain, but there is no good word for pain that is unending and unrelenting.

AARP’s continuing portrayal of many seniors as addicts or drug dealers pushing “narcotic pain pills” is not helpful. Repeatedly labeling us like that has had devastating consequences on pain patients around the country. 

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here. 

AMA: ‘Time to Change Course’ on Overdose Epidemic

By Pat Anson, PNN Editor

With the U.S. facing a record number of drug deaths, the American Medical Association is calling for major changes in the way healthcare providers, insurers, and state and federal policy makers combat the overdose epidemic.

“It’s time to change course,” the AMA says in a new report that documents a 44% decrease in opioid prescribing nationwide over the past decade. At the same time, however, overdose deaths continued rising, fueled primarily by illicit fentanyl, heroin, cocaine and other street drugs.

“With record-breaking numbers of overdose deaths across the country, these are actions policymakers and other stakeholders must take,” AMA President Gerald Harmon, MD, said in a statement. “The focus of our national efforts must shift. Until further action is taken, we are doing a great injustice to our patients with pain, those with a mental illness and those with a substance use disorder.”

The AMA report calls for the CDC to “restore compassionate care for patients with pain” by rescinding “arbitrary thresholds” for opioid doses recommended in the agency’s 2016 prescribing guideline.  Although voluntary and only intended for primary care providers treating chronic pain, the guideline has been widely adopted as a standard of care by states, insurers, pharmacies and physicians of all specialties.

Doctors have also made liberal use of Prescription Drug Monitoring Programs (PDMPs), looking for signs of patients “doctor shopping” or abusing their medications. The databases, which track prescriptions for opioids and other controlled substances, have been accessed 2.7 billion times by physicians, regulators and law enforcement since 2014. State PDMPs were utilized over 910 million times in 2020 alone, according to the AMA.  

As a result of these and other measures to limit opioid prescriptions, millions of pain patients have been tapered to lower doses or completely cutoff from opioids -- yet drug deaths continue rising.

From January, 2020 to January, 2021, over 94,000 Americans died of drug overdoses, the most ever over a 12-month period.

A recent study by the Reason Foundation found that PDMP’s may be making the opioid crisis worse by forcing legitimate patients to turn to street drugs because they lost access to pain medication.

SOURCE: AMA

“The nation’s drug overdose and death epidemic has never just been about prescription opioids,” said Harmon. “We use PDMPs as a tool, but they are not a panacea. Patients need policymakers, health insurance plans, national pharmacy chains and other stakeholders to change their focus and help us remove barriers to evidence-based care.”

One such barrier is limited access to addiction treatment. Although over 100,000 healthcare providers can now prescribe buprenorphine (Suboxone) for the treatment of opioid use disorder, the AMA estimates 80 to 90 percent of people with a substance abuse problem receive no treatment.

The AMA urged policymakers to take these steps:

• Ensure access to affordable treatment for patients with pain, including opioid therapy, by rescinding arbitrary laws and policies that restrict access to pain care.

• Stop insurers from using step therapy and prior authorization to deny or delay treatment for opioid use disorder and other needed medical care.

• Support harm reduction services such as needle and syringe exchange services.

• Make overdose reversal medications like naloxone available over the counter.

• Decriminalize fentanyl test strips and other drug checking supplies.

• Ensure settlement money from opioid litigation cases is used only for public health services.

• Remove structural barriers to healthcare in marginalized and minority communities.

• Improve databases to better track non-fatal overdoses, polysubstance use and local trends in drug use.

“To make meaningful progress towards ending this epidemic, a broad-based public health approach is required. This approach must balance patients’ needs for comprehensive pain management services, including access to non-opioid pain care as well as opioid analgesics when clinically appropriate, with efforts to promote appropriate prescribing, reduce diversion and misuse,” Harmon said.

In recent years, the AMA has become increasingly vocal about the declining quality of pain care in the U.S. and the CDC guideline in particular. In a recent letter to the CDC, the chair of the AMA board said patient stigma and the undertreatment of pain were “a direct result” of the 2016 guideline. The CDC is currently considering an update and possible expansion of the guideline, although a draft revision contains the same dose recommendations as the original guideline.  

“CDC’s threshold recommendations continue to be used against patients with pain to deny care. We know that this has harmed patients with cancer, sickle cell disease, and those in hospice. The restrictive policies also fail patients who are stable on long-term opioid therapy,” wrote Bobby Mukkamala, MD, a Michigan surgeon.

The AMA’s opposition to the guideline drew a rebuke from the anti-opioid activist group Physicians for Responsible Opioid Prescribing (PROP). In a February letter to the AMA, PROP’s board said opioid prescribing for pain was still problematic and “a common gateway to illicit opioid use.” The letter also said that opioid medication should only be used for short-term acute pain and end-of-life care.     

Mission Creep and the CDC Opioid Guideline

By Roger Chriss, PNN Editor

It’s been over five years since the CDC released its opioid prescribing guideline for chronic pain. Now that the agency is looking at possible revisions, it’s worth taking a close look at what research is showing about the effects of the guideline.

First, let’s revisit the goals of the 2016 guideline:

“This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death.”

That’s not what has happened in practice. Instead, the CDC guideline has impacted pain management in both cancer and palliative settings, and has impeded access to care for people with chronic painful disorders.

Cancer and Palliative Care

Several major studies have appeared this year on the effects of the CDC guideline, all finding substantial and unexpected impacts on cancer and palliative care.

An Oregon State University study of over 2,600 hospital patients discharged to hospice care showed a decrease in opioid prescribing and an increase in the use of less powerful, non-opioid analgesics. As result, “some of those patients might have been undertreated for their pain compared to similar patients in prior years.”

Similarly, a study in The Oncologist looked at cancer patients with bone metastasis, and found that opioid prescribing fell significantly between 2011 and 2017. Researchers said their findings “raise concerns about potential unintended consequences related to population-level reduction in opioid prescribing.”

And a study in the journal Cancer found that in interviews with 26 patients with advanced cancer, the majority “experienced stigma about their opioid use for cancer pain management.” Patients also reported difficulties with pharmacies and insurance coverage of opioids.

Chronic Noncancer Pain Care

In chronic noncancer pain management, the CDC guideline has had mixed effects. A recent study in JAMA Network Open concluded that guideline-based opioid prescribing “has potential to improve pain management and reduce opioid-related harms,” but never addressed whether patients thought their pain care actually improved or was even adequate.  

The guideline has also had a chilling effect on some providers. A 2019 study in JAMA Network Open found that over 40% of primary care clinics in Michigan would not accept new patients being treated with opioids due to “decreased social desirability bias.”

The American Medical Association recently reported that many pharmacists have refused to fill legitimate opioid prescriptions, with some patients being told that they were not really in pain and others being subjected to “humiliating accusations that they were drug seekers.”

The AMA shared the experience of one doctor who came back from vacation to learn that he had been blacklisted by a major pharmacy chain that would no longer fill his prescriptions for controlled substances.

“When the CDC guidelines came down in 2016 basically saying we needed to take as many people as we could off opioids, I knew that my patients were in for a world of trouble,” said Aaron Newcomb, DO. “I was particularly concerned about my patients who were stable on low-dose opioid therapy for years. And my concerns have translated into an even worse reality for both me and my patients. Getting blacklisted by a national chain who had no clue about my practice was professionally wrong, but it also hurt my patients and my community.”

The goals of the CDC guideline were laudable. Improving patient outcomes and reducing public health risks are vital to the wellbeing of society. But at least so far, it’s hard to see the CDC guideline as having achieved any of its stated goals. Instead, we have guideline creep and a worsening overdose crisis.

The CDC alone should not be blamed for this outcome. States implemented laws and regulations, in some cases before the guideline was even released, that have contributed to these unfortunate shifts in clinical outcomes. The CDC even warned about misapplication of its guideline, though to little apparent effect.

There is clearly a lot of guideline creep at work. The impacts of the CDC guideline reach far beyond the use of opioids for chronic noncancer pain and are affecting patients in unintended ways, including those suffering from cancer and terminal illnesses or recovering from surgery. Patients and providers are hopeful the upcoming revision of the guideline will address these outcomes and improve pain care.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.  

AMA: Pain Patients ‘Need To Be Treated as Individuals’

By Pat Anson, PNN Editor

The American Medical Association is once again calling on the CDC to scrap dosage limits and make other changes to its controversial 2016 opioid prescribing guideline.

In a letter sent Thursday to a top official at the CDC’s National Center for Injury Prevention and Control (NCIPC), the chair of the AMA’s board of trustees said pain sufferers “need to be treated as individuals” and should not be subject to dose limits. The CDC is currently preparing a revision and possible expansion of the guideline, a lengthy process that could take another year to complete.

“A revised CDC Guideline that continues to focus only on opioid prescribing will perpetuate the fallacy that, by restricting access to opioid analgesics, the nation’s overdose and death epidemic will end. We saw the consequences of this mindset in the aftermath of the 2016 Guideline. Physicians have reduced opioid prescribing by more than 44 percent since 2012, but the drug overdose epidemic has gotten worse,” wrote Bobby Mukkamala, MD, a Michigan surgeon and chair of the AMA board.

The CDC said last week that a record 93,331 Americans died of drug overdoses in 2020. Although the vast majority of those deaths involved illicit fentanyl, heroin and other street drugs, efforts at combating the overdose crisis continue to focus on patients, doctors and reduced opioid prescribing.

“Patients with pain continue to suffer from the undertreatment of pain and the stigma of having pain. This is a direct result of the arbitrary thresholds on dose and quantity contained in the 2016 CDC Guideline. More than 35 states and many health insurers, pharmacies, and pharmacy benefit managers made the CDC’s 2016 arbitrary dose and quantity thresholds hard law and inflexible policy,” said Mukkamala.

“CDC’s threshold recommendations continue to be used against patients with pain to deny care. We know that this has harmed patients with cancer, sickle cell disease, and those in hospice. The restrictive policies also fail patients who are stable on long-term opioid therapy.”

The AMA has been warning about the “inappropriate use” of the guideline since 2018, when its House of Delegates adopted resolutions calling for the elimination of dose thresholds based on morphine milligram equivalents (MME). The CDC guideline recommends that daily doses not exceed 90 MME, a dose that some patients consider inadequate for pain relief.  

Recommendations a ‘Rough Guide’

At a meeting last week of the CDC Board of Scientific Counselors, one of the authors of the 2016 guideline said the MME thresholds were only meant to be “a rough guide” for prescribers and shouldn’t been seen as “absolutes.”

“We heard the concerning reports about the misapplication of the 2016 guideline and we’ve learned from what happened. We know there is a very real possibility that, even with adjustments, the guideline update could be misused,” said Deborah Dowell, MD, Chief Medical Officer of NCIPC.

Critics might wonder if the agency has learned anything in the last five years. A preliminary draft of a revised guideline still contains dose thresholds, recommending that doctors “should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to >90 MME/day.”

An independent panel of outside advisors that reviewed the draft expressed concern about maintaining the dose thresholds, saying they would lead to more forced tapering of patients.

“Though workgroup members recognized the need to have thresholds as benchmarks, many felt that including these thresholds in the supporting text could serve to de-emphasize them as absolute thresholds, and thus recommended removing the specific MME range from the recommendation,” the Opioid Workgroup said in its final report to CDC.

The workgroup also warned that the current draft revision of the guideline was “not balanced” because it focuses heavily on the risks and potential harms of opioids, with less attention paid to their potential benefits. The AMA called on the CDC to adopt the workgroup’s recommendations.

“Patients with pain need the CDC to be their advocate and urge it to rescind the perceived limits on opioid therapy doses or days,” Mukkamala said in closing his letter.

Opioid Income Redistribution

That view is not shared by the anti-opioid activist group Physicians for Responsible Opioid Prescribing (PROP), which sent out a news release this week claiming that prescription opioids are largely responsible for the overdose epidemic.

“Tragically, prescription opioids still account for about 28% of all opioid-related deaths.  Prescription opioids also contribute to synthetic opioid deaths because many heroin and illicit fentanyl users developed their addiction from taking prescription opioids,” PROP claimed. ”Overprescribing of opioids continues to fuel this epidemic. Reducing new opioid prescriptions remains vitally important.”

At least four PROP board members, including founder Andrew Kolodny, MD, have testified as paid witnesses for plaintiff law firms involved in opioid litigation, making as much as $725 an hour. Those law firms stand to make billions of dollars in contingency fees as those cases near an end, with one recent settlement expected to result in a $26 billion jackpot for states, cities and counties. As PNN has reported, many of the lawyers involved in the cases are major political donors.

“Businesses can’t print cash, so where do politicians think the money for these payoffs will come from? The answer is customers in higher prices and workers in lower wages,” The Wall Street Journal said in an editorial.

“The opioid settlement is another example in a growing list of lawsuits that redistribute income from the larger society to rich plaintiff attorneys, who then help politicians with their campaign contributions, who then rehire the lawyers to help with more mass tort claims. Alas, it’s the American way.”

AMA Says CDC Opioid Guideline Still Harming Pain Patients

By Pat Anson, PNN Editor

It was nearly three years ago that the American Medical Association took its first public stand against the CDC’s controversial opioid prescribing guideline.

The AMA’s House of Delegates adopted resolutions calling for an end to the “misapplication” and “inappropriate use” of the guideline by many states, doctors, pharmacists and insurers who imposed hard limits on the amount of opioid medication patients could get, if they could get it at all. Many were left in excruciating pain.

Last year, the AMA went even further, with a 17-page letter to the CDC warning that it was “clear that the CDC Guideline has harmed many patients.”  

Even the CDC acknowledged the 2016 guideline “has been inappropriately cited to justify hard limits or cutting off opioids” and that cancer and surgery patients were suffering as a result.

To date, all of this hand-wringing has changed nothing, as the AMA’s new president recently acknowledged in an exclusive interview with PNN.

“Reports we get from patients and physicians suggest that problems remain. Despite CDC acknowledging that its guidelines should not be used as hard thresholds, there has been almost no effort by state legislatures, health insurance companies, pharmacy chains, or PBMs (pharmacy benefit managers) to evaluate the harmful effects of these one-size-fits-all laws,” said Gerald Harmon, MD, a South Carolina physician who was elected AMA president last month.

“The AMA continues to receive reports that the laws are used to deny, for example, prescriptions for opioid therapy for patients with cancer or in hospice as well as long-time, stable patients with chronic pain.”

DR. GERALD HARMON

Not only has the guideline harmed innocent patients, it failed to achieve its main goal of reducing the risk of opioid addiction and overdose. Opioid prescriptions have been cut to levels not seen in 20 years, while overdoses soared to record highs, fueled largely by illicit fentanyl and other street drugs, not pain medication.

Guideline Meeting

This month we may finally learn what the CDC intends to do after five years of its failed public health experiment, which has been conducted with virtually no effort by the agency to measure its impact on patients. On July 16, the CDC is expected to release a long-awaited draft of a revised guideline during a meeting of its Board of Scientific Counselors (BSC).

(Update: On July 8th, PNN was notified by CDC that the draft guideline would NOT be made public at the July 16th meeting, even though the agenda indicates most of the day will be spent discussing it.

“The draft updated Guideline will not be shared. The BSC Opioid Working Group report is what will be shared and discussed,” CDC spokesperson Courtney Lenard wrote in an email, adding that the public may not get a chance to see the updated guideline until late this year.) 

Although the CDC’s review of the guideline has been underway since 2019, the agency has disclosed no details about its plans, which may include new treatment recommendations for short-term acute pain, migraines and other chronic pain conditions. Even the AMA is in the dark about what the CDC is planning.

“Without seeing a specific proposal, we can’t speculate on what CDC might be considering. We will continue to work with CDC to ensure that any recommendations respect and support care for patients with pain. This includes encouraging CDC to make any drafts open to the public for comment to ensure that any revisions or additions do not make the same mistakes as the 2016 Guideline,” said Harmon.

One of the “mistakes” the CDC made was releasing the guideline during a secretive, ham-handed webinar. The agency also refused to disclose the names of its outside advisors, which included members of the anti-opioid activist group Physicians for Responsible Opioid Prescribing (PROP).  

As recently as last year, the CDC declined to release memos, conflict-of-interest statements and other communications related to the 2016 guideline. Nearly 1,500 pages of documents provided to PNN under a Freedom of Information Act request were heavily redacted or scrubbed of information. Over 1,200 pages were completely blank. 

The CDC is being a bit more transparent this time around. Early in its deliberations, the agency asked for and received nearly 5,400 public comments, most of them from patients who blame the agency for their poorly treated pain. The CDC also made public the identities of a diverse group of physicians, academics and patients appointed to an “Opioid Workgroup” that is advising the agency. Notably, the group includes no members of PROP.

The CDC has not yet disclosed who is writing the guideline revision, although early indications are that at least one of the original three authors is involved again.

“The AMA’s focus will be to continue to advocate that CDC revise its guidelines in an open, transparent manner,” said Harmon. “We continue to urge that CDC specifically remove recommendations tied to hard thresholds and make clear that its recommendations should not be used in state laws or policies implemented by health insurance companies, pharmacy chains, or PBMs.” 

Once a draft of the revised guideline is completed, there will be another public comment period later this year. The CDC may not finalize and release the updated guideline until early next year.

If you’d like to watch the July 16th CDC meeting online, you can register for it here.  

AMA Scolded for Seeking Changes in CDC Opioid Guideline

By Pat Anson, PNN Editor

Eight months after the American Medical Association told the CDC that its controversial opioid guideline has “harmed many patients” and needs to be revised, an anti-opioid activist group has accused the AMA of employing false moral arguments to justify using opioid medication to relieve human suffering.

The letter from Physicians for Responsible Opioid Prescribing (PROP) to AMA President Susan Bailey, MD, takes issue with the AMA’s position that the U.S. “no longer has a prescription opioid epidemic” and instead faces an overdose crisis fueled by illicit fentanyl and other street drugs.

“These statements send a strong message that opioid prescribing for pain is no longer problematic, and that the CDC’s recommended guardrails are no longer needed. Nothing could be further from the truth,” says the PROP letter, which was signed by the organization’s board of directors.

“There is compelling evidence that many of those currently struggling with opioid dependence and addiction were introduced to opioids through use of medically prescribed opioids used to treat chronic pain. Medically prescribed opioids remain a common gateway to illicit opioid use and are themselves frequent causes of opioid addiction and overdose, even if illicit opioids currently cause the greater number of deaths.”

The CDC’s 2016 guideline was only intended for primary care physicians treating chronic pain, but its voluntary recommendations on opioid prescribing have been widely adopted as policy by federal agencies, states, insurers, pharmacies and doctors of all specialties. The guideline has not only failed to reduce drug deaths – which now stand at record highs – but federal health experts admit that widespread misuse of the guideline has caused “serious harm” to patients, including forced tapering, withdrawal, uncontrolled pain and suicide.    

PROP’s letter to the AMA goes even further than the CDC recommendations, suggesting that opioid medications should only be used for short-term acute pain and end-of-life care.  

“All moral, ethical, regulatory, legal and political arguments that opioids are needed so that people do not suffer needlessly should apply specifically to short-term pain management where there is proven benefit, and not to long term pain management where evidence of benefit is largely anecdotal, and there is compelling evidence of harm,” PROP said.

“Why then is the AMA applying the moral argument to the false premise that people will suffer needlessly if they do not have unrestricted access to opioids? By all means apply moral arguments and principles to make sure opioids are available for the right indications, but it makes no sense at all to suggest that removing guidance on opioid dose and duration is needed so that people with chronic pain do not suffer.”

AMA: ‘Misguided Focus’ on Opioids Harms Patients

To be clear, opioid addiction is rare in patients and the AMA never said that people should have “unrestricted access to opioids.” The AMA called for balanced and individualized care based on patient need, not one-size-fits-all guidelines that dictate dosages or the type of treatment everyone should get.    

In a February 19th letter to PROP, AMA President Dr. Susan Bailey said the group mischaracterized the AMA’s position on opioid treatment.

“When policies or organizations focus only on the restriction of a legitimate pharmacologic option to help patients with pain, they miss the chance to address the complexity of policies needed to truly help patients with pain. That misguided focus also has led to harmful stigmatization and other stressors,” Bailey said.

“That is why the AMA provided comprehensive recommendations on the 2016 CDC Guideline and why we continue to advocate for policies that support comprehensive, multidisciplinary, multimodal pain care, including opioid therapy when appropriate.”

“Patients with chronic pain and patients with substance use disorder both need access to multimodal treatments for their medical care,” said Dr. Chad Kollas, a palliative care specialist who is an AMA delegate and Secretary of American Academy of Hospice and Palliative Medicine (AAHPM).

“AMA and AAHPM have recognized the importance of pursuing balanced opioid policy, policy that protects access to opioid analgesics for patients with medically legitimate needs for those medications, while also protecting the public safety and reducing potential harms of prescribed medications.”

Kollas said PROP’s belated response to the AMA’s position may be an attempt to deflect attention away from a recent report that found deaths due to illicit fentanyl soaring, while overdoses involving prescription opioids remained flat.  The research adds to a growing body of evidence suggesting the CDC opioid guideline was ineffective and misdirected.

Although opioid prescribing is at 20-year lows, PROP founder Dr. Andrew Kolodny has said prescriptions “still have a very long way to go” and should be reduced even further. Kolodny recently advised the World Health Organization in the development of a new guideline for treating chronic pain in children, which recommends that opioids only be given to children who are dying or in palliative care.

Slow Progress on Guideline Update

Faced with growing criticism of its own guideline, the CDC announced in 2019 that it was working on an update or possible expansion of its recommendations. Progress has been slow since then.  An advisory group appointed by the agency last summer has had only two preliminary meetings and will not review suggested changes to the guideline until next month, according to an update given Tuesday to the CDC’s Board of Scientific Counselors (BSC).

Draft guidelines are not expected to be available for public comment until the end of this year, meaning any revisions will likely not be finalized until 2022. Patient advocates told the BSC they were disappointed by the lack of progress.

“I would like to urge the members of this panel to please take seriously the issue of timely revision of the CDC guidelines for chronic pain. We have a catastrophe welling out across the country in a wholly marginalized and invisible group. On top of that, we are losing working physicians at a steady rate,” said Terri Lewis, PhD, a patient advocate and rehabilitation specialist. “Everybody is in the gun sights of policy that is not working for anybody. I beg you to please make this an urgent priority.”

AMA: ‘CDC Guideline Has Harmed Many Patients’

By Pat Anson, PNN Editor

The American Medical Association is urging the Centers for Disease Control and Prevention to make significant changes to its 2016 opioid prescribing guideline to protect pain patients from arbitrary limits and other restrictions on opioid medication.

“It is clear that the CDC Guideline has harmed many patients,” the AMA said in a 17-page letter to the CDC.

The letter was in response to the CDC’s request for public comment as it considers an update and expansion of its controversial guideline. The guideline was only intended for primary care physicians treating chronic pain, but the CDC’s voluntary limits on opioid prescribing have been widely adopted as strict policy by federal agencies, states, insurers, pharmacies and doctors of all specialties.

The guideline has also failed to end the so-called opioid epidemic, which is now largely fueled by illicit fentanyl and other street drugs.  

“The nation no longer has a prescription opioid-driven epidemic. However, we are now facing an unprecedented, multi-factorial and much more dangerous overdose and drug epidemic driven by heroin and illicitly manufactured fentanyl, fentanyl analogs, and stimulants. We can no longer afford to view increasing drug-related mortality through a prescription opioid-myopic lens,” wrote AMA Executive Vice President and CEO James Madara, MD. 

“The nation’s opioid epidemic has never been just about prescription opioids, and we encourage CDC to take a broader view of how to help ensure patients have access to evidence-based comprehensive care that includes multidisciplinary, multimodal pain care options as well as efforts to remove the stigma that patients with pain experience on a regular basis.”

Over 5,300 public comments were submitted to the CDC, most of them from patients who blame the agency for their untreated and poorly treat pain. Tuesday was the deadline for comments to be submitted.

One-Size-Fits-All Restrictions

The AMA’s letter points out that opioid prescriptions were declining long before the CDC guideline was released, falling 33% from 2013 to 2018.  

Many patients cutoff from opioids have had no effective alternatives for pain relief. Some non-opioid therapies recommended by the CDC – such as massage and meditation – are still not fully covered by insurance.    

“In many cases, health insurance plans and pharmacy benefit managers have used the 2016 CDC Guidelines to justify inappropriate one-size-fits-all restrictions on opioid analgesics while also maintaining restricted access to other therapies for pain,” Madara wrote. 

The CDC plans to update and expand its guideline to include recommendations for treating short-term acute pain and tapering patients safely off opioid medication.

Madara said the agency should start by recognizing that pain patients need individualized care, not “one-size-fits-all algorithms and policies that do not take individual patient’s needs into account.”   

“Some patients with acute or chronic pain can benefit from taking prescription opioid analgesics at doses that may be greater than guidelines or thresholds put forward by federal agencies, health insurance plans, pharmacy chains, pharmacy benefit management companies, and other advisory or regulatory bodies,” Madara said. 

The AMA said the CDC Guideline could be substantially improved in three ways:  

1. Acknowledge that many patients experience pain that is not well controlled, impairs their quality of life, and could be managed with more compassionate patient care.  

2. Make the guideline part of a coordinated federal strategy to ensure patients receive comprehensive pain care delivered in a patient-centered approach.  

3. Urge states, insurers, pharmacies and other stakeholders to immediately suspend use of the CDC Guideline as an arbitrary policy to limit, discontinue or taper a patient’s opioid therapy. 

The CDC has been slow to respond to criticism of its 2016 guideline. The agency ignored an early warning from a consulting firm that many patients are “left with little to no pain management options” because “doctors are following these guidelines as strict law rather than recommendation.” The warning came in August 2016, five months after the CDC released its guideline.

It took the agency another three years to publicly admit that many patients were being tapered off opioids inappropriately, putting them at risk of uncontrolled pain, withdrawal and suicide. The agency’s long awaited “clarification” in 2019 had little impact on the problem, because many insurers, pharmacies and doctors still adhere to strict dosing policies. 

Even now, the agency appears to be dragging its feet on making revisions to the guideline, which seem more focused on expanding the recommendations rather than fixing them. The CDC does not anticipate the updated guideline to be ready until late 2021.   

AMA: Waive Limits on Opioids During Coronavirus Emergency

By Pat Anson, PNN Editor

The American Medical Association has released a new set of policy recommendations to help patients maintain access to opioids and other prescription drugs during the coronavirus pandemic. While many of the proposals involve substance abuse treatment, some are designed to protect chronic pain patients.

“These recommendations are to help guide policymakers reduce the stress being experienced by patients with an opioid use disorder (OUD) and pain as well as support efforts to continue harm reduction efforts in communities across the United States,” the AMA said in a statement.

The AMA is asking individual states to waive many of the requirements on filling prescriptions for opioids and other controlled substances during the coronavirus emergency.

• Waive limits on the dose and/or quantity of opioids and other controlled substances, as well as refills.

• Waive requirements for electronic prescribing of controlled substances, including requirements for an in-person evaluation of patients needing a refill.

• Waive drug testing and in-person counseling requirements for chronic pain patients needing refills.

• Allow for telehealth counseling to fulfill state prescribing and treatment requirements.

• Provide liability protection for physicians who prescribe controlled substances for patients the physician believes is compliant with prescription recommendations.

• Enhance home-delivery of medication for patients with chronic pain.

The AMA is recommending similar waivers for patients being treated for OUD, including the designation of addiction treatment drugs (buprenorphine, methadone, naltrexone) as “essential services,” allowing for 90-day prescriptions for buprenorphine, and suspending daily limits on residential and out-patient therapy.

The Drug Enforcement Administration recently waived federal requirements for in-person visits for controlled substance prescribing, allowing doctors and patients to connect remotely via telehealth. The AMA is encouraging states to take similar action for their own controlled substance regulations.  

AMA Opposed to ‘Blacklisting’ of Doctors Over Rx Opioids

By Pat Anson, PNN Editor

The American Medical Association is hardening its opposition to public and private policies that seek to limit opioid prescribing. The AMA House of Delegates this week passed resolutions calling for prescribing guidelines to be amended to allow physicians to use their own clinical judgement to decide if higher doses of opioids are medically necessary. The AMA’s ruling body also called for an end to the “blacklisting” of doctors who prescribe high doses.

The AMA didn’t always feel this way about guidelines. When the CDC released its controversial opioid guideline in 2016, the AMA sent a letter to CDC Director Thomas Frieden that “applauded the CDC for treating the epidemic of opioid overdose deaths as a high priority.” And Patrice Harris, MD, a psychiatrist who chaired an AMA Task Force to Reduce Opioid Abuse, said the AMA was “largely supportive of the guidelines.”

Harris, who recently became the AMA President, now says the guidelines “have no basis in science.”

“Physicians can’t be expected to fight the epidemic with one hand tied behind their back, handicapped by policies that limit choices for patients and have no basis in science,” Harris said in a statement.

The AMA House of Delegates finally took a stand against the CDC guideline last November, when it passed resolutions opposing the “misapplication” of the guideline by pharmacists, insurers, pharmacy benefit managers, states and regulatory agencies.  

Although the 2016 guideline is voluntary, it has resulted in many patients being forcibly tapered to lower doses, cutoff entirely or even abandoned by their doctors – all under the guise of preventing opioid addiction and overdoses.

This week’s resolutions by the AMA’s ruling body went a step further, calling for an end to the “inappropriate use” of the CDC guideline to set dosing limits and blacklist physicians who exceed them.  

RESOLVED that our AMA support balanced opioid sparing policies that are not based on hard thresholds, but on patient individuality, and help ensure safe prescribing practices, minimize workflow disruptions, and ensure patients have access to their medications in a timely manner, without additional, cumbersome documentation requirements.

RESOLVED that our AMA oppose the use of “high prescriber” lists used by national pharmacy chains, pharmacy benefit manager companies or health insurance companies when those lists do not provide due process and are used to blacklist physicians from writing prescriptions for controlled substances and preventing patients from having their prescriptions filled at their pharmacy of choice.

RESOLVED that our AMA incorporate into their advocacy that clinical practice guidelines specific to cancer treatment, palliative care, and end-of-life be utilized in lieu of CDC’s Guideline for Prescribing Opioids for Chronic Pain as per CDC’s clarifying recommendation.

The CDC’s so-called clarification came in a commentary published April 24 in The New England Journal of Medicine. Three authors of the guideline did not take any responsibility for the poor implementation of their recommendations, but acknowledged that “some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.”

Nearly two months later, not a single word of the CDC guideline has been clarified or changed, and insurers, pharmacies and many states continue to enforce its voluntary recommendations as mandatory policy.

Doctors who prescribe high doses of controlled substances are also being blacklisted by the DEA and state medical boards, which routinely use prescription drug monitoring programs (PDMPs) to identify and target physicians who are considered “high prescribers.”

Federal prosecutors have also sent letters to hundreds of physicians warning them that their opioid prescribing practices could subject them to criminal prosecution — often without any evidence that their patients were harmed by the drugs.

What Next for CDC Opioid Guideline?

By Pat Anson, PNN Editor

The pain community is reacting with a fair amount of skepticism to efforts by the CDC to address the widespread misuse of its 2016 opioid prescribing guideline.

A CDC commentary published Wednesday in The New England Journal of Medicine warns against the “misapplication” of the guideline, which has resulted in hard dosing limits, forced tapering and the medical abandonment of thousands of chronic pain patients.

Although the guideline strongly recommends that daily doses of opioids not exceed 90 MME (morphine milligram equivalent), the guideline’s three co-authors say their advice was misinterpreted and that the guideline “does not address or suggest discontinuation of opioids already prescribed at higher dosages.”

A CDC media statement this week also claimed “the guideline does not support abrupt tapering or sudden discontinuation of opioids.” 

That was surprising news to Rob Hale, a Missouri man with late-stage Ankylosing Spondylitis, a degenerative and incurable form of arthritis.  Like many other pain patients, Hale’s relatively high dose of opioid medication was significantly reduced soon after the guideline’s release.  As a result, he is now bedridden.

“This is amazing news, if they really intend to follow through with it,” said Hale in an email. “God, I hope this is the beginning of a turnaround in prescribing policies.  I just feel for the hundreds of us who gave up and took their lives or died as a result of the last 3 years of cruelty.”

Saving Face

Why the CDC is acting now is unclear. Reports of patient harm began circulating soon after the guideline’s release in March 2016, and have only accelerated as insurers, pharmacies, states and practitioners adopted the guideline as mandatory policy. In a recent PNN survey of nearly 6,000 patients, over 85 percent said the guideline has made their pain and quality of life worse. Nearly half say they have considered suicide.

“I regard this CDC statement to be an effort to save face and maintain political dominance on an issue into which CDC improperly inserted itself under the influence of Andrew Kolodny and PROP,” said patient advocate Richard “Red” Lawhern, referring to the founder of the anti-opioid activist group Physicians for Responsible Opioid Prescribing.

“The statement fails to engage with the underlying issues which render the Guidelines fatally flawed.  It fails to acknowledge the essential repudiation of the entire guideline concept by the American Medical Association, plus multiple prominent medical professionals.” 

“The CDC guidelines have been as harmful as predicted, and the silence over 3 years has been criminal. The ‘Who me?’ response is just as evil as the ignorant abuse of power that led to the crisis in the first place,” said Mark Ibsen, MD, a Montana physician whose license was suspended by the state medical board for “overprescribing” opioids. A judge overturned the board’s ruling.  

“Those who give a weak ‘mea culpa’ for misinterpretation of the guidelines are, in short, lying. The deaths of thousands of abandoned pain patients, including 6 of mine who lost access (to opioids), are on their hands,” Ibsen said. 

PNN asked a CDC spokesperson if the agency had received new information about patients being harmed by the guideline and received a vague response.  

“We have heard concerns from partners and stakeholders about policies and practices that are inconsistent with the 2016 Guideline and sometimes go beyond its recommendations. The misapplication of the Guideline can risk patient health and safety,” Courtney Lenard said in an email. “CDC authored this commentary to outline examples of misapplication of the Guideline, and highlight advice from the Guideline that is sometimes overlooked but is critical to safe and effective implementation of the recommendations.” 

The response was also vague when we asked if CDC would be directly contacting insurers, pharmacies and states to warn them about misapplying the guideline.

“CDC has engaged payers, quality improvement organizations, state health departments, and federal partners to encourage implementation of recommendations consistent with the intent of the Guideline,” said Lenard, citing a mobile app and a pocket guide to opioid tapering as examples of CDC outreach.

The agency also sent out a Tweet.

Lenard gave no indication that a revision of the guideline was imminent. She said the CDC was working with the Association of Healthcare Research and Quality (AHRQ) to evaluate “new scientific evidence” about the benefits and harms of opioids.  

“Results of these reviews will help CDC decide whether evidence gaps have been addressed and whether the Guideline should be updated or expanded for chronic or acute pain prescribing,” Lenard wrote. 

.@CDCgov #OpioidGuideline does not support abrupt tapering or sudden discontinuation of #opioids. Learn more in our recent @NEJM commentary: https://t.co/vK0ESNyGTU pic.twitter.com/TXZ2jDdMJB

— CDC Injury Center (@CDCInjury) April 24, 2019

Undoing the Damage

The American Medical Association – which took a stand against the “inappropriate use” of the guideline last year -- released a statement saying the CDC needed to work more closely with insurers.

“The guidelines have been misapplied so widely that it will be a challenge to undo the damage. The AMA is urging a detailed regulatory review of formulary and benefit design by payers and PBMs (pharmacy benefit managers),” said AMA President-elect Patrice Harris, MD.

“The CDC’s clarification underscores that patients with acute or chronic pain can benefit from taking prescription opioid analgesics at doses that may be greater than the guidelines or thresholds put forward by federal agencies, state governments, health insurance companies, pharmacy chains, pharmacy benefit managers and other advisory or regulatory bodies.”

Dr. Ibsen said the Drug Enforcement Administration was “the other elephant in the room” because it has weaponized the CDC guideline to demonize and prosecute doctors for prescribing high opioid doses. 

“Arresting and punishing doctors who treat the sickest pain patients. Civil asset forfeiture as used in dealing with criminal drug dealers. Equate physicians with a license to practice as equal to or below said criminal drug dealers,” said Ibsen, listing some of the tactics used by prosecutors.

“Charge physicians with one felony for every Rx they write, making absurdly dramatic charging documents and headlines against doctors who are left with no income or assets to defend themselves in a contaminated jury pool. Charge doctors with murder for prescribing medications to patients who fail to follow the directions.”

It’s not just the DEA. The National Association of Attorneys General recently declared that the dose and duration of opioid prescriptions should not be decided by doctors and that the CDC guideline should essentially be treated as law.

“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,” warns a letter signed by 39 state and territory attorney generals. “As Attorneys General of states with high rates of prescription drug abuse among our youth, policy makers and prescribers must be encouraged to continue to pursue laws and practices that reduce the high volume of opioids in our communities.”

“The standard of care is now determined by prosecutors and juries,” says Ibsen.

Federal Prosecutors Warn Top Opioid Prescribers in Wisconsin

By Pat Anson, PNN Editor

Wisconsin’s two U.S. Attorneys have sent letters to 180 physicians, physician assistants and nurse practitioners in the state warning them that their opioid prescribing practices could result in prosecution.

None of the prescribers have been charged with a crime and it’s not clear if any are under investigation or have been linked to overdoses. Copies of the letters were not released and the recipients were not identified.

According to a news release, the letters warn doctors that they are prescribing opioids at “relatively high levels” that could lead to addiction and that “prescribing opioids without a legitimate medical purpose could subject them to enforcement action, including criminal prosecution.”

“We know that for many, addiction began with opioids prescribed by a medical professional,” said Matthew Krueger, U.S. Attorney for the Eastern District of Wisconsin. “By sending these letters, we are asking medical professionals to join the fight against addiction and ensure they prescribe no more opioids than are necessary.”

“Opioid addiction has touched the lives of far too many families in our state,” said Scott Blader, U.S. Attorney for the Western District of Wisconsin. “Medical professionals play a pivotal role in stemming the flow of legal opioids into unlawful channels.”

According to a spokeswoman, the 180 recipients of the warning letters were selected based on a review of Medicare prescription drug claims, which found that they prescribed opioids above the CDC’s highest recommended dose of 90 MMEs (morphine milligram equivalent). 

“They were identified through Medicare data for two years,” Myra Longfield, a public information officer in the Western District of Wisconsin, told PNN. “And from that data, practitioners were identified where they prescribed on average 90 MMEs (or more) per patient per day. That’s the threshold where the CDC and the Wisconsin Medical Examining Board say there is no real evidence to suggest that above that amount has any better effect on chronic pain.” 

The 2016 CDC opioid guideline is voluntary and only intended for primary care physicians. Longfield said warning letters were not sent to pain management physicians, oncologists or those working in hospice or palliative care, where higher opioid doses may be needed to control pain. 

Chilling Effect on Prescribers

Federal prosecutors in Georgia and Massachusetts have sent similar warning letters to high prescribers. While the intent is to urge caution, critics say the letters are likely to intimidate other doctors.

“This will have a totally chilling effect. The abuse of statistics is pathetic. It would only be an ignorant person that would take the top prescribers and say that they are endangering lives,” said Mark Ibsen, MD, a Montana doctor who nearly lost his medical license over allegations that he overprescribed opioids.  

“After they lop off the top prescribing doctors, guess what that leaves? More top prescribing doctors. Until there are none. Soon we will be seeing tattoos on physicians, similar to POWs.”

“This is an egregious overreach and will lead to more deaths not fewer,” said Lynn Webster, MD, a pain management expert and past president of the American Academy of Pain Medicine. “Using the CDC guidelines as a goal post is not what even the CDC recommended. Most opioid addictions do not begin with a legal prescription of opioids. It usually starts long before exposure to a prescription opioid. The major problem is with illegal opioids smuggled in from Mexico and China. 

“I am worried for tens of thousands of patients in Wisconsin. Many of them will be at risk of suicide or seek illegal drugs, where the real harm exists. Sad. Very Sad.”

Last year, the American Medical Association adopted resolutions opposing the “misapplication” and “inappropriate use” of the CDC guideline. The resolutions by the AMA House of Delegates warn that “no entity should use MME thresholds as anything more than guidance” and that physicians should not be disciplined or prosecuted for prescribing opioids at levels above those recommended by the CDC. The AMA said some patients “can benefit from taking opioids at greater dosages” and “such care may be medically necessary and appropriate.” 

Most opioid overdoses in the United States are now linked to illicit fentanyl and heroin, not prescription opioids. In Wisconsin, 916 people died of opioid overdoses in 2017. Most of those deaths involved either heroin or fentanyl.

AMA: ‘Inappropriate Use’ of CDC Guideline Should Stop

By Pat Anson, PNN Editor

Two and a half years after the release of the CDC’s opioid prescribing guideline, the American Medical Association has finally taken a stand against the “misapplication” and “inappropriate use” of the guideline by insurers, pharmacists, federal regulators and state governments.

Although the guideline is voluntary and only intended for primary care physicians treating non-cancer pain, many pain patients have been forcibly tapered to lower doses, cutoff entirely or even abandoned by their doctors – all under the guise of preventing addiction and overdoses. The CDC has stood by and done nothing to correct the false portrayal of its guideline by insurance companies and pharmacies such as CVS.

The genie may be out of the bottle, but the AMA is now trying put it back in.

At its interim meeting in Maryland this week, the AMA House of Delegates adopted a series of resolutions that call for restraint in implementing the CDC guideline – particularly as it applies to the agency’s maximum recommend dose of 90mg MME (morphine equivalent units).

RESOLVED that our AMA affirms that some patients with acute or chronic pain can benefit from taking opioids at greater dosages than recommended by the CDC Guidelines for Prescribing Opioids for chronic pain and that such care may be medically necessary and appropriate.

RESOLVED that our AMA advocate against the misapplication of the CDC Guidelines for Prescribing Opioids by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit access to opioid analgesia.

RESOLVED that our AMA advocate that no entity should use MME thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME thresholds found in the CDC Guidelines for Prescribing Opioids.

“I was gratified to see these resolutions from AMA. This problem has been developing for some time, but really seems to have picked up steam over the past year, especially with respect to limits placed by pharmacy chains and insurers,” said Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.

“It would have been good to see this kind of statement when various entities first began misinterpreting and misapplying the CDC guideline, but I also understand the need to ensure that a problem develops before proposing a solution.”

“Great to see the AMA is finally stepping up to help bring common sense to the ill-conceived and frankly very harmful CDC guideline,” said Lynn Webster, MD, a pain management expert and past president of the American Academy of Pain Medicine. “Unfortunately too many people have already been a victim of CDC’s misguided attempt to address the opioid problem.” 

Guideline Not Mandatory

Missing from the resolutions is any recognition by the AMA that many of its own members – the organization represents over 200,000 physicians – have been lying to their patients or remain wilfully ignorant about the voluntary nature of the CDC guideline.  

“Earlier this year my doctor explained that he was required to reduce my pain medications. I was shocked. He explained that new opioid prescribing guidelines were requiring patients to be reduced across the board, regardless of their condition,” pain patient Liz Ott wrote in a recent guest column. 

“My current doctor is currently weaning me off the last of my opioids, stripping me of the last tiny bit of medication that have any effect on my pain,” wrote Michael Emelio in another guest column. “After talking to half a dozen pain management doctors this year, I believe that they have been so programmed by the anti-opioid propaganda that many believe they're doing the right thing and fail to realize the true extent of the suffering they have caused.”

“A pharmacist decided to cut my opioid medication in half without permission from me or my doctor. It took 3 months to fix this and find a pharmacy to fill my medication,” wrote Deann Goudy in her guest column.

Even the AMA’s president had a patient – a man with advanced prostate cancer – who couldn’t get an opioid prescription filled by a suspicious pharmacist.

“The pharmacist suspected my patient was a drug seeker and did not alert me that his prescription was denied. My patient, a very proud man, felt shamed and didn’t know what to do. So, he went home to be as tough as he felt he could be. That worked for about three days and then he tried to kill himself,” Barbara McAneny, MD, said in a speech this week at the AMA meeting.

“My patient suffered, in part, because of the crackdown on opioids… When I visited my patient in the hospital as he was recovering from his suicide attempt, I apologized for not knowing his medication was denied. I felt I had failed him.”

The AMA has failed pain patients in the past. In 2016, just months after the release of the CDC guideline,  the AMA House of Delegates recommended that pain be removed as a “fifth vital sign” in professional medical standards – a move that pain management experts warned against because it could lead to delays in getting a diagnosis and treatment.  

AMA delegates that year also passed a resolution urging The Joint Commission to stop requiring hospitals to ask patients about the quality of their pain care. Medicare has a funding formula that requires hospitals to prove they provide good care through patient satisfaction surveys, but critics contended that questions about pain promoted opioid prescribing. They offered no credible evidence to support their claims, but the pain questions were soon dropped from patient satisfaction surveys.

AMA: Patients Being Harmed by Rx Opioid Crackdown

By Pat Anson, PNN Editor

Patients are being harmed by the crackdown on opioid pain medication and increasingly “burdensome” requirements for prior authorization, according to the president of the American Medical Association.

“The pendulum swung too far when pain was designated a vital sign, and now we are in danger of it swinging back so far that patients are being harmed. We need to use our expertise in patient care to change the dialogue to appropriate pain control,” said Barbara McAneny, MD, at a weekend meeting of the AMA. 

McAneny, who is a practicing oncologist in Gallup, New Mexico, shared the story of a patient with advanced prostate cancer who was in severe pain.  

“Metastatic prostate cancer in your bones hurts, and one day he called me to say that his pain regimen wasn’t holding him. So, I increased the dosage of his opioids from two per day to three and of course he ran out early,” McAneny said. “So, I called his primary care physician who agreed to write a prescription for his very large amount of time-release morphine.” 

When the patient tried to get his prescription filled, the pharmacist called the insurer for prior authorization and was denied. The pharmacist also checked the prescription drug monitoring program (PDMP) and found that the patient had multiple prescriptions written by McAneny and other doctors.  

BARBARA MCANENY, MD (AMA PHOTO)

“The pharmacist suspected my patient was a drug seeker and did not alert me that his prescription was denied. My patient, a very proud man, felt shamed and didn’t know what to do. So, he went home to be as tough as he felt he could be. That worked for about three days and then he tried to kill himself,” said McAneny.  

“Fortunately, his family found him in time, and the emergency medicine physician was able to save his life. He spent a week in the hospital and finally we got his pain back under control, on the exact regimen I had prescribed him as an outpatient.”  

Ironically, the insurer paid for the patient’s ambulance and hospital bills without any prior authorization. And the CDC’s “voluntary” opioid guidelines — which have been widely adopted by insurers — don’t even apply to cancer patients.

“Like you, I share the nation’s concern that more than 100 people a day die of an overdose. But my patient nearly died of an under-dose. This story illustrates the problems we all confront every day in our current dysfunctional health care system,” McAneny said. “The health plan does not have the chart, doesn’t know the patient, and basically countermanded my orders without even telling me using the prior authorization process. How have we let health plans determine the course of care? They call this quality? 

“My patient suffered, in part, because of the crackdown on opioids… When I visited my patient in the hospital as he was recovering from his suicide attempt, I apologized for not knowing his medication was denied. I felt I had failed him.”

McAneny cited a 2017 AMA survey, which found over 90% of doctors believed prior authorization led to delays in treatment and had a negative impact on patient outcomes. Nearly a third of doctors had to wait at least 3 business days for a prior authorization decision to be made.  

New prior authorization rules to be adopted by Medicare on January 1 could lead to delays in treatment for millions of elderly and disabled pain patients on high doses of opioids. Prescriptions over 200mg MME (morphine equivalent daily doses) will trigger a “hard edit” safety alert requiring pharmacists to consult with the prescribing physician before filling a prescription. Insurers will also be given greater authority to identify beneficiaries at high risk of addiction and to require they use “only selected prescribers or pharmacies.”

Don’t Let the Media and Medical Profession Fool You

By Richard Oberg, MD, Guest Columnist

Chronic pain patients, like my wife, myself and others with abominable mistreatment, continue to lose the care they need while nothing is being done to address the real issues.

Drug abuse is up, young people are dying and the main culprits aren't prescription drugs, but something much more difficult to control. Heroin and illicit fentanyl, major causes of the increasing deaths, are becoming more widely available and, unfortunately, both of them are opioids.

The media routinely spouts about these “opioid deaths” while implying that prescription pain medication is what caused healthy people to take these illegal drugs. Why? Because they say so, that's why.

As with the recent 60 Minutes nonsense, they embellish the death of some high school quarterback, have a room full of grieving parents who say they had no idea their kids were drug addicts, add the fear that this can happen to you, and we the patients get to bear the brunt of this misdirected insanity.

The CDC addictionologist lobby and other federal agencies seem to have hoodwinked everyone into blaming chronic pain patients for this national problem. This is obvious and evident from countless stories of patient abuse no one seems to want to hear. The word is “scapegoat” and not a single person in power is responsible for anything – only we the patients are.

The CDC, government agencies and, quite frankly, the majority of physicians are NOT well-intended on this issue. They created this patient crisis that could have been avoided.

Don't let the medical profession that I was a part of for nearly four decades fool you. Physician sub-specialty organizations now exist for the benefit of physicians, not patients, and are mostly about maintaining control and money. Had these organizations stood up to defend patients against the CDC, and the ridiculous addictionology cohort of psychiatrists and anesthesiologists grooming their financial turf, we wouldn't be here right now. But they didn't, and a majority of physicians say they actually support the guidelines.

Don't buy the “they made me do it” line. It is misdirected nonsense, just as eliminating the pain scale to prevent any accountability is. Physicians don’t like accountability.

Inevitably, doctors still willing to write prescriptions for pain meds will attract greater numbers of chronic pain patients – and become easy prey for the DEA or their physician colleagues who don’t approve. Some of these doctors will become outliers in medical associations whose members tell them to stop because they don’t want to see or treat patients like us.

Why doesn't anyone ask where all the patients of physician practices that are being shut down go to? It's because no one in power cares, that's why. And then there’s the sheer ignorance or bigotry of many physicians who profess to be “pain management experts.”

The American Medical Association (AMA) once represented 75% of all licensed physicians and supported the best care for patients. 

Today, membership in the AMA has declined to just 15-20% of physicians, as subspecialty organizations gained power and patient care became driven by those isolated subspecialties. 

These organizations support the flow of wealth to their specialties better than the AMA ever could.  With increasing specialization, patient care became highly fragmented for those with complex diseases, yet there was no attempt or incentive to coordinate care. It became every patient for himself.

It is extremely rare to non-existent for a physician specialist to actually speak to another physician about your care, nor is much if any time spent reading another doctor’s evaluations. It’s just not fiscally expedient with current healthcare models. That is why you’re “re-evaluated” by every new specialist you see and have to reprove your illness over and over, often to skeptical stares.

The major problem with this is that subspecialties often “evaluate” you beyond their competence. For example, a rheumatologist is vastly superior to a psychiatrist if you have an autoimmune disease, but if you’re depressed and miserable because of an undiagnosed autoimmune disease and enter the care of a psychiatrist, the odds of ever getting an appropriate diagnosis are nil. Worse, they can make your life hell.

It’s just not what they do -- they make you fit their model – not the other way around. Whenever you get into the care of some subspecialist unlikely to have any idea what’s wrong with you, it inevitably leads to biases against you because physicians are just as bigoted about what they don’t understand as anyone else.

The attitude of most that my wife and I have encountered (despite both of us being physicians) suggests that most subspecialists get their information from the nightly news rather than medical journals outside of their specialty. Neurosurgeons think opioids are bad because that’s what they’ve heard. And they’d rather believe that than have you tell them otherwise.

From our point of view, it’s would almost be comical if it wasn't so infuriating.

Often, chronic pain patients are not sick enough to warrant hospital care (following acute care protocols), yet are too ill to be seen by outpatient physicians who aren’t reimbursed enough to spend additional time figuring you out or interacting with your other physicians.

And there are plenty of “well patient” visits providing better income – so why bother?

If this sounds bad, it’s because it is. For those who like their anesthesiologist pain care person, good for you. Many of us aren’t so fortunate. And someday you might not be either.

I’m not sure how much worse this will get, with patients losing access to opioids or seeing their doses cut, while overdose death rates continue to rise -- refuting CDC wisdom. Taking meds from chronic pain patients isn’t going to fix a problem caused by healthy people with illegal intentions.

Maybe some powerful mainstream media source will actually ask someone in power what's going on and not settle for anything other than a straight answer. But I wouldn’t hold my breath.

Take the unfortunate demise of Prince and how it has been reported. Whenever someone with career-induced injuries attempts to defeat aging by taking illicit opioid pain medication to continue performing 20 year old moves on a 57-year old body, bad things will result. It shouldn’t be rocket science to figure that out, yet I don’t recall a single media source saying that.

Instead, Prince has become another idiotic reason legitimate patients shouldn’t get opioid pain care – all because he intentionally misused it to extend his career. Because of the actions of a few, the vast majority will suffer. Not exactly stellar for the most expensive healthcare system in the world, is it?

Richard Oberg, MD, is disabled by psoriatic arthritis and no longer practices medicine. Dr. Oberg receives no funding from pharmaceutical companies. 

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.

AMA Defends Dropping Pain as Vital Sign

(Editor’s note: Last week we published a story on the American Medical Association’s decision to support the removal of pain as a “fifth vital sign” in professional medical standards – a move that some believe will make it harder for pain patients to be properly diagnosed and treated. Patrice Harris, MD, Chair of the AMA’s Board of Trustees, sent us the following letter objecting to how the AMA’s vital sign policy was characterized by PNN.)

By Patrice A. Harris, MD, Guest Columnist

The American Medical Association (AMA) unequivocally supports a patient’s right to receive the highest level of compassionate, comprehensive care for his or her pain.  It is unfortunate that the recent actions at the AMA House of Delegates were painted as anti-patient (“AMA Drops Pain as Vital Sign”), when the actual debate was focused entirely on how to ensure physicians have the necessary tools to deliver optimal care to our patients. 

Reducing the stigma of pain and advocating for comprehensive pain care are key recommendations from the AMA Task Force to Reduce Opioid Abuse – part of our multifactorial plan to ensure that balanced policies are in place to ensure patient’s access to care and promote the best evidence-based pain management practices, while reversing the nation’s opioid misuse, diversion, overdose and death epidemic.

When called for by a physician’s clinical judgment, this includes the use of opioid analgesics as a potential component of individual treatment plans.

Contrary to the claims in the article, however, our new policies complement and further our longstanding advocacy that emphasize the importance of treating each patient as an individual and tailoring care for that individual.

PATRICE HARRIS, MD

Pain satisfaction surveys, physician satisfaction surveys, even the Joint Commission’s Pain Care standards have not been shown to result in comprehensive improvements in pain treatment or protocols, or improved outcomes, but are clearly motivating forces for opioid prescribing. 

Patients with chronic pain deserve to benefit from the research and scientific approaches as envisioned by the National Pain Strategy, which the AMA strongly supports.  Not a single physician said, suggested, or hinted that anyone should “stop asking patients about their pain” as your recent article suggested.  Perpetrating this baseless, stigmatizing claim does your readers a tremendous disservice and does not reflect the opinions or practice of the nation’s physicians. 

We are well-aware that efforts to reduce the supply of opioids in the United States, without due consideration for unintended consequences and impact on chronic pain patients, have taken firm hold, and that many such patients have experienced disruption in their care and suffered. Many physicians at the AMA meeting decried the stigma that their patients experience. Others highlighted the audits and investigations by law enforcement among their colleagues.  And many noted the importance of treating all physical, psychosocial and behavioral aspects of pain. 

Furthermore, all discussed the importance of effective, evidence-based care, including the fact that vital signs are those that can be objectively measured and quantified. Identifying, treating and managing pain is central to medical practice, but it is not a readily quantifiable physiologic vital sign.  

We recognize that the pendulum has clearly swung too far. We know that the stigma of pain and opioid use has become pervasive, and we believe physicians and patient advocates must work together to restore balance.  But we can’t ignore the fear and stigma that pervades our society – and affects physicians and other health care professionals. We see (and experience) the increased scrutiny by law enforcement and government regulators.

In response, some physicians no longer treat chronic pain or prescribe opioids. But there are committed physicians in every city, town and state who provide the type of compassionate care that our patients need and deserve.  There are many examples of physicians doing all that is necessary to provide the type of complex, thoughtful care that chronic pain patients need. That is the vision we have for pain care in the United States.

We will, always stand up and speak out in support of patients who are in pain. We have done this countless times in Congress, with our state and specialty society colleagues, in front of the National Association of Counties, National Conference of Insurance Legislators, National Governors Association and many other leading organizations. 

We know all too well that pain is the number one reason patients come to us. We will continue to seek all avenues to provide the care our patients need – whether pharmacologic or non-pharmacologic – and insist that insurers cover the multimodal therapies required for effective management of chronic pain. 

The nation’s opioid misuse, overdose and death epidemic has harmed far too many, and the AMA is committed to working to ensure that patients with pain are not among those who must now become innocent bystanders in the regulatory response to this public health epidemic. To suggest anything less is to ignore the body of our advocacy and the mission that is central to our proud history.

Patrice A. Harris, MD, is Chair of the AMA Board of Trustees and Chair of the AMA’s Task Force to Reduce Opioid Abuse. A practicing psychiatrist based in Atlanta, Dr. Harris has served on the board of the American Psychiatric Association, as President of the Georgia Psychiatric Physicians Association and as Director of Health Services for Fulton County, GA.

Pain News Network invites other readers to share their stories with us.  Send them to:  editor@PainNewsNetwork.org. 

The information in this column should not be considered as professional medical advice, diagnosis or treatment. It is for informational purposes only and represents the author’s opinions alone. It does not inherently express or reflect the views, opinions and/or positions of Pain News Network.