News feeds are filled with painful images of people fleeing their home countries because of war, criminal violence, or political chaos. Here in the United States, a different kind of refugee population is growing: people losing homes and families to a prescription painkiller addiction that started in a doctor's office.
In 2012, physicians wrote a stunning 259 million prescriptions for opioid pain medications. We are seeing levels of opioid prescribing previously found only in hospice settings. This is leading to harm — addiction, heart problems, breathing problems, fractures, disability, and death — without effectively addressing the underlying causes of pain. The casualties are mounting. Since 1999, about 140,000 Americans have died of overdoses. In 2013, the death toll was more than 16,000, and the issue has frequently taken center stage during the 2016 US presidential campaign.
Within the medical community, a growing consensus has emerged over the need for physicians to self-correct. Perhaps it isn't surprising that some clinics and large health systems are dismissing patients from their practices, saying, "We don't treat pain with opioids anymore."
We must not let the pendulum swing too far and turn everyone away. Desperate patients increasingly are turning to alternatives like heroin to ease the painful symptoms of opioid withdrawal — and they end up dying as a result.
Physicians Embrace CDC Guidance
That's why we need to adopt the new US Centers for Disease Control and Prevention (CDC) draft guidelines on chronic pain. The CDC guidelines recommend that we use opioids cautiously, that we not start a new generation of people on chronic daily opioids, and that we help people on high-risk regimens transition to safer doses. These recommendations clearly emphasize the need for a slow taper, because dismissing patients from a practice "can adversely affect patient safety, could represent patient abandonment, and could result in missed opportunities to provide potentially lifesaving information." The guidelines can reduce the frequency of people being abruptly cut off from medications they have taken for years.
The CDC guidelines contain a thorough review of the evidence, are thoughtful and patient-centered, and make common sense. I haven't met a doctor who doesn't like them. A new Sermo survey of 1,600 physicians found 87% said they would welcome and use the guidelines.
More than 4,000 people and organizations filed public comments on the guidelines. Many were positive, but quite a few comments were critical of the guidelines and blamed the CDC for demonizing painkillers. Sample comments: "We are being tortured by the medical community because the doctors are so afraid to prescribe." "Are you trying to kill us?" "What the CDC is doing . . . should be considered a crime against humanity." "I get punished for what junkies and addicts do."
These critical comments are surprising, because the guidelines explicitly caution prescribers against stigmatizing patients. "Opioids are not good or bad," says Dr. Andrea Rubinstein, chief of pain medicine at Kaiser Permanente in Santa Rosa. "They are a molecule — one that can create great benefit and can cause egregious harm."
The worst type of harm that can happen to a person, of course, is death, and most people who die from opioids are taking drugs prescribed by their own doctor. This fact seems counterintuitive, until you look at some of the super-potent pills being prescribed for common conditions. For example, one 80-milligram Oxycontin pill, typically taken three times a day, is equivalent to 16 Vicodin tablets. If a patient forgets whether he took his bedtime pill and takes another — or if a teenager takes one at a party — it is like swallowing a handful of pain pills.
Food, Water, and Dopamine — the Keys to Survival
Years of taking high-dose opioids change the dopamine system, the brain's reward and motivation network. "You need three things to survive — food, water, and dopamine," says Dr. Corey Waller, a Michigan-based pain and addiction specialist and a sought-after speaker on the opioid epidemic. "If you take opioids long enough at high enough doses, the dopamine system breaks. New studies show that the brain takes years to recover, and sometimes it never does."
As we rein in excess prescribing, we need to ensure that patients on high-dose regimens have clinicians equipped to either help them taper to a safer dose or switch them to a safer option like buprenorphine. The guidelines make it clear that buprenorphine, the first medication for opioid use disorder that can be prescribed or dispensed in physician offices, has an important role to play in tackling this problem. Buprenorphine is a very potent, long-acting opioid painkiller that stabilizes the dopamine system in the brain and prevents withdrawal. However, it acts like an "anti-opioid" (antagonist) in a very important way: It doesn't stop people from breathing, so the risk of death plummets. Understanding this fact helps opponents realize why "treating a drug problem with a drug" is so effective — 50% of people stay in treatment, instead of 7%. The death rate for people on buprenorphine is a small fraction of the death rate for those with no treatment, according to the American Society of Addiction Medicine's practice guideline for the use of medications in the treatment of addiction involving opioid use. Buprenorphine is an option for pain patients as well — even for those without addiction who are taking high-risk levels of painkillers. "Many of my patients are never able to get off opioids," says Rubinstein. "But if I transition them to buprenorphine they can lead normal lives, and they won't die from an overdose."
We spent years trying to do the right thing by treating patients' pain, but now the right thing must be redefined. Above all, we cannot turn our back on the opioid refugee.
I applaud the national safe-prescribing movement, and we at CHCF are supporting community coalitions across California to implement safer prescribing practices. But good prescribing guidelines will still not be enough for patients who already are dependent or addicted. The CDC guidelines can show us a good path if we don't misinterpret them. Let's honor the core of our profession: take care of people, and do no harm.