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An Epidemic of Undertreated Chronic Pain

I was relieved to to read the headline “A Mea Culpa on CDC Opioid Guideline” in Pain Medicine News. Mea Culpa means a formal acknowledgement of fault or error, and gives me hope that the pendulum on opioids may be moving closer back to center. The 2016 CDC guidelines really cemented the medical hysteria around opioids (see timeline for further exploration) and rapid adoption of their strict opioid dosage ceilings and duration limits has resulted in widespread undertreatment of chronic pain. Even though studies show that patients taking opioids for chronic pain have a low risk of developing addiction, the presumption of “All Opioids Are Bad” seems to be everywhere now.

The Mea Culpa article describes how the authors of CDC guidelines themselves have recently acknowledged problems with their adoption, noting that some of the “policies and practices purportedly derived from the guidelines have in fact been inconsistent with, and often go beyond, its recommendations."And they are absolutely right that their recommendations have been taken to extreme levels. In Oregon, our state Medicaid plan is proposing mandatory opioid tapers for all chronic pain patients, which advocates (myself included) have been fighting against for over a year. Other medical providers are speaking out as well.

Even the current president of the American Medical Association, Dr. Barbara McAneny is fed up: “[Patients have] suffered… because of the crackdown on opioids. The pendulum swung too far when pain was designated a vital sign, and now we are in danger of swinging it back so far that patients are being harmed. We need to use our expertise in patient care to change the dialogue back to appropriate pain control.”

In response, the CDC convened a multidisciplinary expert panel to review the guidelines and their published report identified that regulators and policymakers have applied the guidelines “without flexibility and sometimes without full awareness of what the guidelines contain.” The panel’s report also highlights other problems with implementation of the CDC Opioid Guidelines:

  • Improper application of dosage ceilings and prescription duration guidance

  • Failure to appreciate the importance of patient involvement in decisions to taper or discontinue opioids

  • Barriers to diagnosis and treatment of opioid use disorder

  • Impeded access to recommended comprehensive multimodal pain care

Clearly we need to find a middle ground, one that enables access to opioids for chronic pain management while limiting abuse and addiction. The biggest challenge is the lack of access to effective alternative non-opioid treatments. So until we have other choices in our pain toolbox, opioids must remain an option, while continuing efforts to minimize their risk of addiction and abuse.


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