In a
New England Journal of Medicine commentary published today, the authors of the
opioid prescribing guidelines that the U.S. Centers for Disease Control and Prevention issued in 2016 reiterate the agency's
recent warning that it does not recommend abrupt or nonconsensual tapering for patients who are already taking high doses of narcotic analgesics for chronic pain. "Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations," write Deborah Dowell, Tamara Haegerich, and Roger Chou. Those policies and practices, they say, include "inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician's practice."
Dowell, Haegerich, and Chou warn that patients forced to reduce their doses "could face risks related to withdrawal symptoms, increased pain, or unrecognized opioid use disorder" and "if their dosages are abruptly tapered may seek other sources of opioids or have adverse psychological and physical outcomes." They also worry that doctors are responding to the CDC's advice about the potential risks of opioids by "dismiss[ing] patients from care" or declining to prescribe opioids at all, "even in situations in which the benefits might outweigh the risks." Dowell et al. say "such actions disregard messages emphasized in the guideline that clinicians should not dismiss patients from care, which can adversely affect patient safety, could represent patient abandonment, and can result in missed opportunities to provide potentially lifesaving information and treatment." And they note that the guidelines have been improperly applied to "patients with pain associated with cancer, surgical procedures, or acute sickle cell crises."
The CDC's recognition that misinterpretation of its guidelines has resulted in needless suffering, patient abandonment, and "adverse psychological and physical outcomes" (including suicide) is welcome, if overdue. "This article should allay anxiety among physicians who prescribe responsibly for patients with chronic pain," says Sally Satel, a Washington, D.C., psychiatrist who helped organize a
March 6 letter to the CDC in which hundreds of health professionals and addiction specialists, including three former drug czars, expressed concern about the unintended consequences of the CDC's advice. "No longer can any clinician, insurer, health care system, or pharmacist claim 'the CDC Guideline says' when it comes to tapering or discontinuation."
Stefan Kertesz, a University of Alabama at Birmingham pain and addiction specialist who worked with Satel on the letter to the CDC, was also heartened by the
NEJM article. "We needed CDC and its guideline's authors to do precisely what they have done, which was to speak with vigor and clarity to the pressing ethical concern we laid out in our letter," he says. "In affirming that the guideline did not call for hard dose cutoffs and forced tapers, the guideline's authors have effectively called for recalibration of policies by insurers, by Medicaid authorities, and by agencies that have set 'the number of patients above a given dose' as the primary indicator of bad care."
The letter to the CDC included
testimony from hundreds of patients who have suffered the consequences of that ham-handed approach. "The trauma to patients who have been living in terror these past three years nearly broke my heart many times," Kertesz says. "The only possible step has been for people familiar with the nexus of science and health policy to speak openly about the problems we have seen, and to trust that most people ultimately want to do what's right."
