The opioid guidelines are back in the national news. The debate about prescription pain inhibitors rages on multiple fronts. Just over three years ago, the Center for Disease Control published guidelines on the prescribing of these medications. See Opioid Guidelines from the CDC - Finally (March 2016). 

A fair amount of attention has been devoted to opioids in this blog. Opioids can Interfere and Complicate, PDMP and Opioids in Ohio (includes a list of multiple related posts). As a society, there seems to be significant disagreement between those who are experiencing pain and thus need opioids and those who are concerned with the rate of prescribing, the potential downsides, and even overdose. 

One physician that has written extensively on opioids is Dr. Charles Argoff. He concludes that the results of the Guidelines have been "significant adverse consequences to the person in pain." In a recent article, he notes that "three of the authors" of the CDC Guidelines have noted misapplication which they say "can risk patient health and safety." Dr. Argoff notes that "misapplication of recommendations" poses a risk to patients. This is particularly pertinent to those "outside of the guideline's scope," such as "active cancer treatment patients, people experiencing sickle cell crises, or people experiencing postsurgical pain."

Another article on Statnews delineates that the CDC Guidelines authors have said "that doctors and others in the health care system had wrongly implemented" the Guidelines. They stressed that the Guidelines are not a "“inflexible application of recommended dosage and duration thresholds." They decry "hard limits and abrupt tapering of drug dosages.” As to tapering those already taking high doses of opioids, the two noted "we know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them.”

There are those who feel there are pharmacy industry influences at work in the pain debate. Recently, Medical Express reported that two U.S. Congressional Representatives have accused the World Health Organization (WHO) of including "false claims about the safety of prescription opioid painkillers" in a recent report. They assert that these "WHO guidelines could result in" similar opioid crises in other countries. There is allegation that this is an effort to bolster distribution elsewhere as use in the U.S. is decreasing. 

TheFix recently published an article stating that “criticism of the guideline follows a consistent pattern." The authors note there are critics, but that the critics provide "no evidence . . . to refute any statement in the guideline." These physicians are seemingly asking where is the proof against the Guideline or the proof of it having deleterious effects. There is an allegation that opposition to the Guideline is connected to the pharmaceutical industry. The authors contend that: 

"Opioid manufacturers stand to lose substantial profits with the widespread adoption of the CDC guideline. Public health, however, benefits from the guideline, and attacks on it bear industry’s fingerprints." 
The American Medical Association (AMA) has published a new report, detailed on the website of Orthopedics this Week, which says that physicians have "cut opioid prescriptions 33%." That decrease between 2013 and 2018 amounted to "80 million" "opioid prescriptions." That is a significant volume. Note, however that "80 million" is a third of the prior volume. This suggests that the annual volume remains at about 160 million, which is likewise significant. 

The AMA conclusion is that prescribers must be judicious, and that prescribing nonetheless remains potentially "medically necessary and appropriate." The author takes no position on whether prescription opioids were "a significant trigger for the nation's opioid crisis," but conclude unequivocally that "the main causes of the problem are now elsewhere." The suggestion being that prescriptions may no longer be the primary concern, encouraging more focus on street drugs. However, the implication is that prescriptions remain of concern and worthy of ongoing attention or study. 

In 2017, I noted that overdose was significant. The 2016 numbers were available, and in The Hot Seat, Opioids, Marijuana, and More I noted that in 2016 64,000 Americans died of overdose (that is more than the Americans that died in the Vietnam conflict). We might hope to impact that rate, with all the attention this crisis has now received. In 2017, the CDC says there were 70,237 deaths; "opioids were involved in 46,700" of those, "67.8% of all overdose deaths." The death rate is increasing. A CDC prediction tool says that 2018 is anticipated to evidence about 66,986. The decrease was also reported last year by Time. It urges "cautious optimism." Certainly a decrease is good news, but what is hoped for is continued downward trend; 67,000 is not a figure to celebrate except in that it may mark a beginning. 

Pew Research reports that "Americans overwhelmingly see drug addiction as a problem." It is a problem that is growing in "urban, suburban, and rural counties." It notes "substantial increases in fatal drug overdose deaths" have been experienced by "whites, blacks and hispanics." In short, Pew reminds that this is everyone's problem. And, it seems to be getting worse. Despite this, there are various reports of populations that are more starkly affected. CBS News reported that the overdose death rate for "females aged 30 to 64 have skyrocketed," increasing "260 percent from 1999 to 2017." 

USA Today reports also that Millennials are particularly affected. It says that "young adults were more likely than any other age group to die from drugs, alcohol, and suicide over the past decade." It suggests that these adult's are experiencing mental health issues that are tied to debt they have incurred for education, the challenges of graduating into the "great recession," and their perceptions of where they are in society. Thus, while it seems fair to say opioids remain an issue for society at large, there are indicators that some populations are experiencing greater impact than others. 

So, where does all this leave America? First and most obvious is that death remains a serious concern with drugs. It is possible that the death rate peaked in 2017, and that continued downward trending might be expected. However, even at the 2016 level, drug overdose deaths rival suicide, nephritis, influenza, and diabetes according to the CDC. Something over one-half million Americans died of overdose between 1999 and 2017 (19 years). At 64,000 annually (2016 number), we will lose that many every 8 years. Therefore, it is clear significant challenges remain.

Many of the news cites linked herein make mention of the role that Fentanyl plays in the current crisis. As a street drug, it is increasingly available, deathly potent, and a significant public health threat. Addressing the role that it and other street drugs play in this health crisis would be an appropriate next step in stemming the death and overdose rates.

But, in the end, it appears that there is no demonstrated foundation for criticism of the CDC Guidelines. It should be noted that first, they are Guidelines. Second, it is important that the Guideline critics cite no evidence that is critical of the Guidelines themselves. The criticism is seemingly directed instead at the application and use of those Guidelines, as to when they should be (not with end-stage cancer patients) applied, and how they should be interpreted regarding people with long-term dependency already established.

In fairness, the subject of pain is complex. There are those who need such medication. There are those whose reactions to such medication will be more profound than others'. And, in the end, we have to be able to trust doctors to make hard decisions about who,  how much, and how long. The Guidelines seemingly help in that analysis process, but cannot be absolutes or inflexible. Human beings are different, as are situations and circumstances.

While the commentators are urging that attention be turned to the street drugs now, there has been little suggestion of what those efforts could or should be. If the rate of overdose is to be addressed, how would that best be approached? Can the flow of Fentanyl and Heroin be stemmed? That is a supply issue. Can the users that purchase and use these be convinced to decrease consumption? That is a demand issue. In the economics of the problem, perhaps there are ways for us to address both supply and demand?


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    About The Author

    • Judge David Langham

      David Langham is the Deputy Chief Judge of Compensation Claims for the Florida Office of Judges of Compensation Claims at the Division of Administrative Hearings. He has been involved in workers’ compensation for over 25 years as an attorney, an adjudicator, and administrator. He has delivered hundreds of professional lectures, published numerous articles on workers’ compensation in a variety of publications, and is a frequent blogger on Florida Workers’ Compensation Adjudication. David is a founding director of the National Association of Workers’ Compensation Judiciary and the Professional Mediation Institute, and is involved in the Southern Association of Workers’ Compensation Administrators (SAWCA) and the International Association of Industrial Accident Boards and Commissions (IAIABC). He is a vocal advocate of leveraging technology and modernizing the dispute resolution processes of workers’ compensation.

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