By Dr. Lynn Webster, PNN Columnist
Jack Schwartz (a pseudonym) is a toddler of Holocaust survivors. As a small boy, he was traumatized by observing his older brother develop into hooked on heroin. He additionally developed a substance use dysfunction of his personal that he believes was due, partly, to childhood PTSD.
A 64-year-old psychotherapist, Schwartz has been in persistent ache since a 1996 automobile accident injured his neck. Though he has a historical past of substance use dysfunction, he has used opioids to handle his ache for the previous a number of years.
His private doctor, who retired on the finish of 2020, wrote a letter stating Schwartz has been prescribed Norco (a mixture of acetaminophen and hydrocodone), has been compliant, and has proven no indicators of abuse for the earlier 4 years. The retiring physician hoped Schwartz would be capable of discover somebody to proceed prescribing his Norco.
Schwartz has not but discovered a brand new doctor. Within the meantime, his insurance coverage firm notified him that they might not pay for his medicine, citing the CDC’s opioid prescribing guideline and their very own opioid coverage, which states that “narcotics will not be the remedy of alternative for persistent nonmalignant ache.”
Schwartz contacted me after studying a PNN column I wrote, “Ironic Partners: Suicide Prevention and Pain Awareness Month.” He stated he was suicidal and requested me for recommendation. We agreed that sharing his story may assist others in comparable positions.
Who Ought to Write Medical Pointers?
Regrettably, Schwartz’s state of affairs is just not unusual. Many insurers and regulators have adopted rigid policies that cite the CDC’s voluntary guideline as if it was the usual of care. The CDC has admitted its guideline is being misapplied and is engaged on an replace, however to this point the company has completed little to right the issue.
In reality, the CDC has gone even additional than the rule of thumb, producing a reality sheet for physicians, “Nonopioid Treatments for Chronic Pain,” by which it recommends various medicines for frequent persistent ache circumstances together with migraine, low again ache, osteoarthritis, fibromyalgia, and neuropathic ache.
Why is the CDC making medical remedy suggestions?
Cardiologists and coronary heart surgeons ought to develop suggestions for managing coronary heart illness. Endocrinologists ought to provide suggestions for managing diabetes. Infectious illness specialists ought to make suggestions for managing infections. Habit specialists ought to present suggestions for treating dependancy. And it’s ache specialists who ought to develop remedy tips for treating ache.
The way in which it ought to work is that this: Skilled organizations representing medical specialties develop remedy tips. Every time potential, enter needs to be solicited from affected person stakeholders. The function of presidency organizations such because the Nationwide Institutes of Well being, FDA, CDC, and DEA needs to be to supply knowledge and sources to those teams, to allow them to provoke and revise remedy tips because the science evolves.
Specialists ought to prepared the ground to make sure affected person care is clinically pushed and patient-centered. Non-clinicians, comparable to authorities officers — even when they’ve medical levels— shouldn’t be making remedy selections or creating tips for specialists and their sufferers.
Strolling Again the CDC Guideline
For my part, it was a mistake for the CDC to launch the rule of thumb in 2016. Earlier than it was revealed, I predicted people in pain would suffer and that the rule of thumb wouldn’t cut back the variety of opioid-related overdose deaths. Sadly, I was correct.
Many suppliers, sufferers and their family members have urged the CDC to revise or withdraw the rule of thumb. The American Medical Association has urged the CDC to make “important revisions.”
The three co-authors of the rule of thumb, Deborah Dowell, MD, Tamara Haegerich, PhD, and Roger Chou, MD, even wrote a commentary for The New England Journal of Medicine in 2019 acknowledging that their suggestions have been being misapplied and have been “prone to end in hurt to sufferers.”
The admission that the CDC guideline was dangerous was lengthy overdue. Now the query of how the suggestions needs to be modified should be addressed. Hopefully, the CDC will take into account enter from individuals who have been harmed probably the most by the rule of thumb and can revise their suggestions accordingly.