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Fighting Words is the opinion column of Tonic. Send the pitches to [email protected].
After three years of increasing the number of serious injury cases in patients with chronic pain – including dozens of suicides of people whose medications were interrupted and hundreds of disability stories Increased – The Center for Disease Control and Prevention (CDC) has released a critical clarification of its 2016 directive on opioid prescribing for chronic pain.
Earlier this month, the Food and Drug Administration (FDA) also issued an urgent warning stating clearly that doctors should not gradually reduce patients dependent on these drugs. The agency has also recognized the risk of suicide associated with rapid reductions in concentrations and other psychological and physical dangers to patients.
It is time for these agencies to address the widespread suffering caused by opioid repression as a result of the predictable misapplication of the 2016 directive.
Lawyers are cautiously optimistic that the changes will begin to restore balance in a policy that has ignored the plight of chronic pain sufferers, while relentlessly focusing on reducing the supply of drugs. Opioids for medical purposes.
"I am deeply grateful to both the FDA and the CDC for having decided to speak now because it allows us all to have a serious conversation" about the disadvantages and benefits of the directive, says Stefan Kertesz, Professor of Preventive Medicine at the University of Alabama in Birmingham. Kertesz was one of the main organizers of a letter recently sent to the CDC by the group of health professionals for people with pain, who asked for such clarification.
The guideline recommended that physicians be cautious when prescribing opioid doses greater than 90 morphine equivalents (a means of comparing opioids of different strengths) and generally avoiding prescribing drugs. opioids for chronic pain, to the extent possible. Introduced into a country facing the worst overdose crisis in its history, it was not surprising that what was supposed to be a set of recommendations quickly became legal rigor and insurance.
Although the CDC has stated that it does not intend to prohibit the prescription of opioids in high doses or to force existing patients to stop smoking, these results have been widely reported. Insurers, regulators, pharmacies and state legislators have turned the document (which was supposed to be flexible so as not to harm patients with complex needs) into a set of rigid rules without exceptions. And the guideline has also been misapplied by these groups to include patients that it has never been intended to cover, such as people with cancer, those with post-surgical pain and those taking drugs to treat addiction.
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"I'm pleased to see these points made so explicit, although I'm sure some will say" too little, too late, "said David Juurlink, head of Sunnybrook Health Sciences' Clinical Pharmacology and Toxicology Division. Toronto Center and board member of one of the leading organizations that advocated the development of the guideline, Physicians for a Prescription for Opioids.
"To be fair to CDC, these same messages were clear from the first day for anyone who bothered to read the guidelines," adds Juurlink. "To the extent that the recommendation was problematic for patients with chronic pain, it was not the recommendations themselves, but rather their misapplication."
One of the many erroneous applications was the legal pressure on doctors by medical councils and prosecutors, who often targeted physicians to deviate from CDC recommendations. Many of these doctors have responded by forcing their patients to reduce their doses or to completely stop the medications, affecting thousands of Americans. Even at present, at least one state is considering imposing on all Medicaid patients with certain pain diagnoses to stop opioids, whether they benefit from it or not.
But as explained by the authors of the clarification (who were also the authors of the 2016 guideline), New England Journal of Medicine:
Policies should allow clinicians to consider the unique circumstances of each patient when making clinical decisions …
An unintended consequence of clinicians' expectations for high dose opioid risk reduction is that, instead of attending to high-dose patients or involving and helping patients reduce their dosage, some clinicians may find it easier to dismiss or remove patients.
Clinicians could universally stop prescribing opioids, even in situations where the benefits could outweigh the risks. These actions do not take into account the messages highlighted in the guidelines that clinicians should not exclude patients from care, which could be detrimental to patient safety. [and] could represent the patient's abandonment.
Kate Nicholson is a former federal and patient prosecutor who has previously needed opioids in the past. In March, she and other advocates met with CDC officials to lobby for change and explain how the patients were injured.
"I am pleased that the CDC and the FDA are taking steps to protect patients," she said. "They basically agreed to do just about everything we asked them to do." She added that "it's only a beginning, given the overall, the guidelines have been misapplied." at all levels of the health system. "
Kertesz agrees. "It is crucial for institutional actors who have misapplied this directive to take seriously the fact that the CDC and the FDA have expressed themselves clearly," he said.
He added: "Quality measures, public and private [insurance companies] who militarized the directive by invoking its authority while ignoring what it said in plain English must recalibrate. They have to do it urgently. "
As someone who has covered the heartbreaking stories of people who have lost loved ones to suicide as a result of these policies – and who spoke to dozens of patients who became bedridden or became less functional after being able to work and take care of their family – I am also happy to see this change.
Removing the medications needed by patients with pain does nothing to combat addiction – and pretending that opioids play no role in treating chronic pain denies both scientific and clinical experience. The inexcusable commercial commercialization of opioids to doctors has now affected not only drug users, but also two distinct groups of patients suffering from pain: those who benefit from opioids and are now denied treatment, and those who do not. do not benefit but are gradually reduced. without support or alternative.
Lelena Peacock, a pain patient who has spent a lot of time trying to help people who become suicidal after losing access to medication, has recently made a gradual reduction in her use.
"I have been abandoned medical care as countless patients under opioids in the long run," she said. "We are now treated as parolees, not patients. We are viewed as unmanageable liabilities that threaten the freedom and livelihood of health professionals at all points in the continuum of care …. The doctor / patient relationship was almost completely destroyed. This relationship is now punitive. What took the CDC so long?
We have a long way to go before we can solve these problems – but at least the agencies concerned have finally recognized their existence and have begun to change course.
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