April 18, 2017
This large survey of pain patients and healthcare providers found that most patients had an unfavorable impression of CDC Opioid Prescribing Guidelines, which were released in March 2016.
Interview with Paul Christo, MD, MBA, and Pat Anson, National Pain Report editor
An online survey by Pain News Network (PNN) and the International Pain Foundation1 found that both patients and healthcare providers have an overwhelmingly unfavorable impression of the Centers for Disease Control and Prevention (CDC)’s voluntary opioid prescribing guidelines, first released in March 2016.2
More than 3,100 chronic pain patients and 278 doctors, pharmacy employees, and other healthcare professionals took the survey in early 2017; results suggest that about 95% of patients believe that the CDC's guidelines hurt pain patients. About 40% of healthcare providers thought the new guidelines were hurting patients, and another 30% didn’t know.
Almost half of patients reported having a harder time finding doctors to treat their chronic pain, and close to 85% are in more pain, likely due to the fact that about 70% of them are now being prescribed lower doses of opioids—or none at all. (Editor's Note: About two-thirds of PNN readers use opioids to manage their pain.3)
Some patients are hoarding opioids (22%) and/or getting hold of then illegally (11%). More than 42% of respondents have considered suicide. At the same time, 85% of patients and more than 65% of healthcare providers think the guidelines have not reduced opioid abuse or overdose.
About the Survey
The survey was created by PNN President and Editor in Chief Pat Anson, in consultation with several pain experts. Respondents were recruited via PNN’s email newsletter, website, social media, and through affiliates.
While it was not a scientific study, “I do think it's a fairly good indication that the guidelines have resulted in harm to many patients, and created a fair amount of uncertainty and even fear among prescribers,” Anson said.
Are Attempts to Curb Abuse Misguided?
The survey also found that “relatively few patients were referred to addiction treatment (4%) or were discharged for failing a drug test (4%)” Anson pointed out. “That would indicate to me that the misuse and abuse of opioid medication is rare among pain patients—yet they are often blamed for fueling the nation's opioid epidemic.”
“Most patients with chronic pain using opioids therapeutically do so responsibly,” agreed pain specialist Paul J. Christo, MD, MBA, a Practical Pain Management Editorial Board Member who also hosts a radio show “Aches and Gains.”4
He cited a recent study showing that less than 13% of patients “presenting to the emergency room for opioid overdoses carried a diagnosis of chronic pain.5 Unfortunately, the war on opioids is hurting certain patients who need them the most.” Dr. Christo is Associate Professor in the Department of Anesthesiology and Critical Care Medicine at Johns Hopkins University School of Medicine in Baltimore.
Interpreting the Guidelines
Among other recommendations, the CDC urges primary care physicians to exercise caution in prescribing 50 or more morphine milligram equivalents (MME) a day, and avoid prescribing 90 MME or more a day. Note: the CDC guidelines are designed for primary care physicians, and are not meant for specialists. In fact, the American Pain Society and the American Academy of Pain Medicine, which represent pain specialists, consider 200 or more MME a high dose.6
Furthermore, while the guidelines are voluntary, “Too many providers [30%, according to the survey] either don't know [that], or believe the guidelines are mandatory,” Anson noted, adding that the guidelines are prompting insurers to decline to cover long-term opioid treatment. Indeed, 57% of healthcare providers reported that insurance companies have refused to cover pain treatment they thought patients should receive.
Anson added that federal agencies are also making some guidelines mandatory: A new law in Maine, for instance, prevents doctors from prescribing chronic pain patients (not including those receiving cancer treatment or palliative care) more than 100 MME a day, and patients currently taking more than that should taper down by July 2017.7,8 In North Carolina, the state’s medical board, which adopted and endorsed the CDC’s guidelines,9 may now investigate some opioid prescribers.10 These kinds of laws help illustrate why more than 35% of health care providers worry about being prosecuted or sanctioned for prescribing opioids, according to the survey.
“The survey indicates that we need to strongly support patients … and highlights the chilling effect the CDC guidelines are having on the lives of chronic pain patients,” Dr. Christo said.
“Doctors and patients also agreed overwhelmingly that the guidelines have worsened the quality of pain care, not improved it,” Anson concluded. “Insurers may think they are reducing costs and reducing liability by making it harder for doctors to prescribe pain medication, but in the long run they are creating millions of chronically ill patients that are bedridden, unable to work, or disabled because their pain is untreated or under-treated. The long-term costs to society will be immense, and we're just starting to see the fallout.”