"The health and vitality of our people are at least as well worth conserving as their forests, waters, lands, and minerals, and in this great work the national government must bear a most important part."– Theodore Roosevelt
"Was the government to prescribe to us our medicine and diet, our bodies would be in such keeping as our souls are now." -Thomas Jefferson
The quotes above, from two of our nation's most revered leaders, illustrate the complex difficulties surrounding the question of what to do about the opioid crisis – at least from the standpoint of prescriptions. I'm known in my community as the anti-opioid guy. Yet when my colleague Dr. Beth Darnall asked me to sign on as one of the stakeholders in a recent appeal to the U.S. Department of Health and Human Services decrying forced opioid tapering, I didn't hesitate to lend my support to the effort. Keeping the ship upright requires some back and forth crew movements on the deck.
I don't claim to speak for everyone whose name appeared on that paper by any means; expected heterogeneity of opinion (and underlying data) abounded in our antecedent dialogue. Yet we all chose to sign it out of some sense of common ground, and my aim in this brief post is to clarify that synoptic perspective and to further elaborate on four 'known knowns' I trust we can all rally around. I'm also leaning a little on the AMA's recent resolution on the issue, and have cited that document below as pertains to each point. Allow me to do so at the outset here to summarize for those with limited time or attention: ("... no entity should use MME thresholds as anything more than guidance...")
Lest we forget
Point One: We remain in an opioid overuse crisis. We musn't lose sight of the huge public health problem – and the public is made up of individuals. Most opioid-related deaths are not suicide. I don't need to belabor the point here; suffice it to say that overdose deaths (from both illicit and prescription agents) continue to climb year after year, and if we can all get behind improving traffic safety surely we can coalesce around the vital statistics here. Not to mention that's just the tip of the iceberg – individual and relational dysfunction related to opioid dependence is manifold. (AMA: "[We] applaud the Centers for Disease Control and Prevention (CDC) for its efforts to prevent the incidence of new cases of opioid misuse, addiction, and overdose deaths.")
We have met the enemy ...
Point Two: The risk-benefit ratio is unfavorable. There's a time and place for opioid prescribing; historically we've agreed that severe (and generally acute) pain refractory to more conservative means comprises when failure to adequately treat severe acute pain may lead to chronification, among other consequences. However, it's probably safe to say that most of us now recognize that initiating chronic opioid therapy (COT) – even if that means simply writing a second prescription of hydrocodone – is often a slippery slope and one that's increasingly difficult to harmonize with primum, non nocere.
Good data show that in the majority of cases, not only is COT in chronic non-cancer pain (CNCP) not beneficial, it's often actually harmful and problem-perpetuating. And we're not just talking overall morbidities – CNCP itself feeds on COT. Microglial TLR-4 receptor activation (and other opioid-induced hyperalgesia mechanisms) aren't the only issue either; pain is a biopsychosocial-spiritual issue often dramatically affected by COT. Depression, erosion of resilience, and self-efficacy are indisputably linked to long-term use.
Is there a Doctor in the House/Senate?
Point Three: The government (let alone corporate attorneys) shouldn't practice medicine. The difficulty obviously lies in discerning and shepherding the best path out of those harms for the so-called legacy opioid patients. Sailing back through Scylla and Charybdis is even tougher than traversing them in the first place, and if it's tough for well-intentioned subspecialist experts, how on earth are the elected or appointed supposed to know how to do this?
Traditionally the federal government limited its involvement to public health (for which most of us are grateful for when it comes to Ebola and cigarette taxes.) More and more, however, Washington is assuming influence over medicine – either directly or in convoluted ways, e.g., CMS. But for the purposes of this post, it's important to keep in view that at least at the time of this writing, aside from the incontrovertible provisions of the Controlled Substances Act, the Feds have kept to advisory and not regulatory activity when it comes to opioid prescription. On the other hand (and Mr. Jefferson would be proud), the states have historically carried the mantle of regulating medical practice. Some have suffered more obviously from this crisis as a result of complex societal pathology including poor prescribing practice, and are increasingly adopting postures that, while perhaps laudable from the standpoint of epidemiology, may well prove disastrous at the individual level. (AMA: "[We oppose] the legislating of numerical limits on medication dosage, duration of therapy, numbers of pills/tablets ... .")
What's even more troubling is the incursion of private entities into the once-hallowed ground of the physician's sole investiture to exercise professional medical judgment in the patient's best interest. Granted, we as a profession have done a poor job of regulating ourselves, but that doesn't justify retail headquarters taking it upon themselves to decide when it's appropriate to dispense medication. While perhaps not tantamount to practicing medicine without a license, doesn't overriding physician decisions threaten our entire healthcare system? If obstruction of medical care leads to patients under duress making the (admittedly criminal) choice to turn to street drugs, or God forbid, ending their own lives out of desperation, when do we call corporate (or the legislature) to accountability? (AMA: Such decisions by pharmacies or pharmacists can interfere with the practice of medicine and ... good quality patient care ... [we] recommend that [pharmacy chains and benefit managers] cease and desist with ... presenting policies, procedures, and directives to retail pharmacists that include a blanket proscription against filling prescriptions for opioids ... .")
Winning Hearts and Minds
Point Four: Simply taking opioids away from people isn't a good idea. Heroin and suicide are two obvious reasons, and I'd like to think we can all agree on that. We have to replace opioids, which are ultimately sought for comfort, with a truly biopsychosocial-spiritual, preventive, self-management, and resilience-enhancing approach. Fortunately, well-thought out consensus statements such as the National Pain Strategy, and large-scale trailblazing efforts such as the EMPOWER trial on voluntary patient-centered prescription opioid tapering, are directing us to respect and harness the primacy of behavioral health in de-emphasizing opioids and revamping how we do pain management in this country. (AMA: [We] encourage the Federation of State Medical Boards ... medical specialty societies, and other entities ... to develop improved guidance on management of pain.")
In our small practice (sans behavioral health professional), we've seen vastly improved outcomes when simply applying concerted time and attention to biologic contributors such as sleep deprivation, poor nutrition, poor posture, and lack of exercise, and also basic cognitive/emotional distortions associated with long-standing pain. Two years' worth of PMP data showed that our "usual care group" managed a median MME reduction of 38.5%, whereas those more intensively supported by a formal holistic program ("Resume Course©") showed a median reduction of 95% (P=0.03). And for what it's worth, 15.6% of the usual care group successfully discontinued COT during that period compared to 30% of the Resume Course© group (P=0.08). We didn't do more interventional procedures in the latter group; we did however spend on average 30 minutes per month more with them. And therein maybe lies the chief difference; demonstrating care, encouraging, and challenging – in the context of facilitating more primal wellness needs (thank you Dr. Abraham Maslow) – is indispensable.
Pendulum swings in medicine aren't new, but damping the oscillation rarely bears such urgency. To paraphrase the original document, we call on our leaders to:
- Recognize that opioid tapering requires evidence-based careful selection, patient-centered methods, realistic goals, and close monitoring for adverse events.
- Include the expertise of pain management subspecialists at every level of decision-making about future opioid policies and guidelines.
- Put a halt to policies forcing opioid tapering/cessation outside the contexts of diversion or unequivocal, documented harm: benefit ratio imbalance.
Heath McAnally, MD, MSPH, is a board-certified anesthesiologist, pain physician, and addictionologist practicing in Alaska (the military sent him there and he decided to stay). If he wasn't trying to guide people in improving their own lives, teaching medical students to do the same, or writing about it, he'd probably be outdoors right now slogging up a mountain with a good friend or two.
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