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The crisis started from good intentions by public health authorities. Over the years, as poor outcomes resulted, the complexity of the situation became more widely understood. And yet, as recently as last month, a unit of the Centers for Disease Control refused to consider changing the guidelines that have hurt people as much as, or more than, they help.
In 2009, the Obama FDA forced Purdue Pharma to reformulate their popular pain medication, OxyContin, which had been the primary substitute to produce heroin for the user on the cheap. In theory, forcing a reformulation would make conversion impossible, thus pushing users away from abuse and addiction.
This turned out to be an enormous mistake. Without access to OxyContin, users adopted black-market heroin, rendered with cheap but exceedingly dangerous fentanyl, eventually becoming centralized in the illicit drug pipeline. Suddenly, first-time users, from dabblers to hard-core heroin addicts, began dropping dead.
But prescription opioids only ever played a minor role in the crisis. Medical surveys, autopsy reviews, and statistical analyses overwhelmingly find prescription opioids solely responsible for about 1% of the deaths. Diversion of legitimate medications (onto the black market) also just plays a small part in the fatalities. When autopsies are performed, prescription opioids are almost always a small fraction of a large cocktail of illicit substances; those abusing them are seldom recipients of legal prescriptions.
However, as reported by author Gerald Posner, some prescribing practices do need to be addressed. Rural areas with poor economic outlooks — particularly in Appalachia and industrial Ohio — often contained reckless, illegal “pill mills.” Furthermore, it is fair to say American medicine swung too far, as demanded by public health professionals, in the 1990s toward full pain relief.
That was when the “fifth vital sign,” pain, was introduced into medicine — itself a necessary but radical overcorrection for the opioid phobia that dominated most of the 20th century.
If only then, prudence won out. Pain and addiction patients got treated with the compassion they deserve. Their needs are not oppositional.
These guidelines represented an even more radical swing in the other direction, restricting pain medication for almost everyone. Law enforcement agencies and state legislatures especially took this guidance as a hard rule that justified a crusade against prescription opioids — a crusade that would hasten the deaths of law-abiding patients and addicts alike.
Five years have elapsed since the guidelines’ release, and the overdose crisis is graver than ever. Today, millions of patients are without access to pain treatment, including children, the disabled, veterans, African-Americans and cancer patients. Yet, the number of those abusing illegal drugs is virtually unchanged.
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Without the CDC’s endorsement to remedy past blunders, Congress and public health officials will push for ever-stricter and more punitive medical access for anyone who ever needs pain relief, undoubtedly creating further tragic overdose deaths. That science proves this is a terrible idea does not seem to matter to the CDC.
And the public health profession appears to be about to make matters considerably worse, with outright prohibition of opioid painkillers.
Noticing the suffering of millions of innocent patients harmed by those exceptionally unhelpful and misfocused restrictions, the American Medical Association announced its public opposition, forcing the CDC in December of 2019 to announce an opioid work group to revise and update the guidelines by 2021.
I attended that meeting; tears were shed by advocates and CDC employees alike. Finally, it seemed wiser heads would prevail. More than a few desperate patients told me afterward that if they could only hold out till the CDC corrected their guidelines, all would be well.
Then COVID-19 arrived. At some point in 2020, the internal politics of the CDC shifted dramatically. Unbeknownst to the work group members, their regulatory authority got shunted to the NCIPC, an infamously political arm that busies itself with the contagious diseases of gun violence and traffic accidents. Or as one scientist told me, the NCIPC is where solutions go to die.
Last month, on Feb. 16, the NCIPC made it clear, in that classic bureaucratic way of saying everything with nothing, there had been a change of plans. Now there would be no admission of fault for its own role in the overdose crisis, neither would they attempt to fix the harm created by their own guidelines.
To give you an idea of how little the NCIPC cares about the crisis, a total of 10 minutes centered on this work group, with no discussion of deaths or patient abandonment. Instead, officials spent 30 minutes congratulating one another for their oh-so-courageous handling of the coronavirus.
As a final insult, the panel disregarded federal law on public comments, and played games with its video-conferenced meeting, claiming that none of the public bothered to show up, making it impossible for everyone but four individuals to give testimony during the comment period.
To those watching, the CDC’s conduct felt sickening. Several stunned members of the work group communicated they were not notified of the meeting beforehand and were shocked at the change. Advocates put together petitions voicing their concerns and shock, while dozens of widely respected front-line clinician-scholars, like Dr. Stefan Kertesz of the University of Alabama-Birmingham school of medicine, sent complaints.
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Medical professionals are right to be alarmed. The CDC’s policies fatally flattened the complexity of treating pain and addiction, let alone the difficulties in combating drug abuse. Important clinical algorithms determining physicians’ treatment options are heavily influenced by the guidelines. Moreover, the guidelines became a clarion call to public health agencies worldwide for opioid prohibition.
For example, in the United Kingdom, there is the National Institute for Health and Care Excellence guideline forbidding treatment for chronic pain. European Pain Federation guidelines ban pain treatment except for secondary pain syndromes. The World Health Organization, disturbingly, announced that children with cancer be restricted access to pain therapies unless terminally ill.
Considering the swath of anti-patient laws enacted in the CDC’s name around the world, the only means to stanch this profuse hemorrhage in human lives — and refocus efforts where they really count — would be for the CDC to unabashedly acknowledge the guidelines’ destructiveness and unequivocally protect the physician-patient relationship.
It should proclaim that patients again have access to medication under their watchful physicians’ eyes. Anything less would be insufficient to fix the significant harms the CDC enabled.
Catastrophically, the reverse occurred.
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This change in priorities by the CDC endorses the ever-tightening restrictions with an overdose crisis raging unabated.
The word is out in public health, and the new gospel is Total Opioid Prohibition.
Medical students are today warned to stay far away from the now radioactive profession of pain medicine, particularly addiction and chronic pain management.
President Biden’s new surgeon general, Obama administration repeat Dr. Vivek Murthy, is an anti-opioids partisan. Under Biden’s leadership, Health and Human Services is attempting to substantially undermine medical privacy, just as the DEA creates a universal prescription monitoring program circumventing HIPAA protections.
Congress is more than happy to play along. CARA Act 2.0 is a bipartisan bill waiting in committee that, if made law, would make attaining opioids even for acute care difficult, limiting prescriptions to no more than three days, as is recommended by the CDC.
With draconian state laws, chilling prescription drug monitoring programs and Narxscores (aimed at identifying patients at risk of addiction), adding in a three-day limit will cement full-blown prescription opioid prohibition — generating an ever-rising flood of human misery.
Your loved ones are unlikely to be spared.