Pain Management and the 2016 COVID-19 Pandemic: Implications of a High Dosage Opioid Use Recommendation

The guidelines show that while opioids should not be the most popular treatment for many cases, other treatments and approaches are comparable in terms of improving pain and function. However, the recommendations make clear the guidance should not replace clinical judgment and that clinicians can work with patients who are in pain, even if that means continuing them on opioids.

Patients who are abandoned to withdrawal and untreated pain have an increased overdose death risk of nearly 300 percent, and their risk of suicide is also significantly elevated. If thousands of them hadn’t been cut off, the street market for Fentanyl would have been less than it is. It is both cruel and nonsensical to increase patients’ risk of overdose death and suicide in an attempt to reduce these harms.

The CDC leadership has taken a hit during the COVID-19pandemic and it is dependent on them to coordinate and fix harms that came from the 2016 guidance. There were criticisms and harms from the last round of guidance. He hopes the CDC can take the guideline and translate it to the ground level.

The guidelines are meant to guide shared decision-making between clinicians and patients, says Christopher Jones, acting head of the CDC’s National Center for Injury Prevention and Control.

The change in outlook is evident all over the new guidelines, says Dr. Samer Narouze, the president of the American Society of Regional Anesthesia and Pain Medicine.

While the voluntary guidelines are a welcome step, their impact depends largely on how state and federal agencies and other authorities respond to them, says Leo Beletsky, professor of law and health sciences at Northeastern University and director of the Health in Justice Action Lab there.

The definition of high-dosage opioid use, in the 2016 recommendations, was used to set legal limits. He says the 2016 guidelines were clear that this was not a bright line rule but it became a defacto label. law enforcement used the limit as a sword to go after prescribers.

These doses and limits – set without much scientific evidence to back them up – have had a chilling effect on doctors, says Cindy Steinberg, a patient advocate with U.S. Pain Foundation.

According to the medical director of the Pain Management Services, they are very comprehensive and compassionate. The guidelines made a blanket cut off for patients and that’s not what pain management is about, these arbitrary marks of what is acceptable and not acceptable are what got us into trouble.

Reducing opiate use when possible still raises some concerns for clinicians like Dr. Stephan Kertesz, the professor of medicine at the University of Alabama atBirmingham.

“I would emphasize that when you take a stable patient and reduce [their prescription], you’re engaged in an experiment,” says Kertesz. Sometimes dose reduction can help and sometimes it can cause patient to die. So I would rather they have said, ‘Look, this is an uncertain intervention.”

He adds that the strength of the new guidance is its emphasis that a specific dose shouldn’t be used by law enforcement and agencies to enforce a one-size fits all approach.

Dose Thresholds in Drug Delivery for Substance Abuse: Implications for Treatment and Quality Management in the Era of Addiction

An older patient of hers was suffering from severe arthritis in her neck and knees and she remembers one instance when it happened. “I recommended to the primary care doctor to start low-dose opioids and the primary care doctor said ‘no,’ ” Barreveld says. “What happened? The patient was admitted to the hospital, thousands of dollars a day for eight days, and what was she discharged on? Two to three pills a day, that’s how many of them there are.

The previous guidelines lead to the creation of policies or law. It’s not clear those rules will be re-written in light of the new guidelines even though they state they’re “not intended to be implemented as absolute limits for policy or practice.”

That is a great idea, but it will not have any effect unless three agencies act immediately. “The DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, all three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality metrics and legal investigation.”

“If somebody has access to these life-saving medications, it cuts their mortality risk by 50 percent,” says Dr. Linda Wang, a researcher who treats patients with addiction at Mount Sinai Hospital in New York City.

As a result, public health officials say only one in 10 Americans struggling with addiction ever receive treatment. Studies show that people of color have a hard time getting access to treatment.

Those policies left millions of people vulnerable as the powerful, toxic synthetic opioid fentanyl spread in the U.S., making addiction even more dangerous.

“There were significant barriers that were quite stigmatizing for patients as they enter treatment,” says Dr. Neeraj Gandotra, chief medical officer for the Substance Abuse and Mental Health Services Administration (SAMHSA), the federal agency that oversees addiction.

Even though people may be able to get the drug, often they have to visit a government approved clinic many times a week to get it.

It is a major barrier that they aren’t allowed to get take- homedoses, because they have to go to the clinic daily.

There was no evidence of diversion increasing or risk decreasing, but people who gained access to treatment did better.

Do We Need a Rules Change for Opioid Recovery Medicines? A Case Study of a Phoenix, California, opiate-treatment program

The rule- change would make those reforms permanent. It would also eliminate waiting periods for access to methadone and expand telehealth options even further.

Gandotra says the term “detoxification” will no longer be stigmatized by federal rules when it comes to opioids treatment programs.

She is about to get her PhD in justice studies at the Arizona State University, and she credits the help of the pill for stabilizing her life.

But she also says she’s faced years of stigma and surveillance within the opioid treatment system, where she often felt less like a patient and more like a criminal.

During the pandemic, Russell says she was finally allowed to take home a month’s supply of her medication at a time. She was able to avoid going to the nearest clinics every day, a 45 minute drive from her home in Phoenix.

Currently, only a limited number of certified opiate-treatment programs will be allowed to sell methadone.

Some addiction experts and government officials say the ultimate goal is for opioid recovery medicines to be regulated like medications for other chronic diseases.

” It’s too early to say if this rule change is a step toward that.” I am unsure how far along we have to go, even though we believe it is.

Do doctors need help? The U.S. attorney general should contact the D.E.A. and the federal prisoner’s attorney general

She contacted many doctors to find care. She said the C.D.C.’s Opioids Rapid Response Program was meant to help when pain clinics are closed or large numbers of patients lose doctors for any reason. “It was almost like they thought I was out of line, even ridiculous, for calling them,” she said. The program has difficulty finding physicians who will help such patients, and is in the process of studying why they are rejected.

The U.S. attorney general should send a similar letter to the D.E.A. and its prosecutors, telling them to stop pursuing doctors simply because they prescribe high quantities of opioids or drugs that are potentially dangerous. If there are no other signals of criminal intent, this is a matter of medical judgment and possible malpractice, not an issue that should be handled by federal law enforcement. Agencies like the C.D.C. need to make sure that there is no impact on patients’ care if agents find doctors dealing drugs.

People who suffer pain are not responsible for America’s addiction problem. Denying access to needed medication does not help anyone. At least one man and his wife have already died by suicide following the closure of the clinic Ms. Fuqua attended.