In 2017, the CDC rolled out a “solution” to the opioid crisis. The recommendations, which were never intended to become laws, were mostly level of evidence three or below. To put it another way, they were not robust, nor were they based on research in any way that matters. There was also no input from the pain medicine associations. The premise was that we would solve the problem using what those of us who work in the field call a “supply-side” policy. In other words, if it becomes really difficult to prescribe opioids, that will result in everyone getting sober and there being no more drug problems! The guidelines reasoned that all we have to do is take everyone who is currently prescribed an opioid and taper them down to 100 morphine equivalents or below! Bam! Consider it done! I understand why it was seductive to follow the idea of an easy algorithm that would allow anyone, even without expertise, to risk-stratify a very complex group of patients. But it’s not easy, and I actually do have expertise. To be clear, I am board certified in addiction medicine and was treating “the opioid crisis” for at least ten years before everyone else realized it was the new hotness. I was enforcing controlled substance agreements when everyone else didn’t need them because “I know my patients.” I also do a lot of pain management, as does my husband, who practices pain medicine full time. And we were in agreement that this intervention was a really, really bad idea. If the problem had been COPD, policy writers would listen to the pulmonologists. When it was COVID-19, everyone listened to the infectious disease people. Do you know what I got when I frantically told all my colleagues in surgery, internal medicine, and the emergency department that this policy was a huge mistake and would cost lives and accomplish nothing? When I pointed out that over 90 percent of people prescribed opioids use them appropriately, so going after pain patients was the wrong pressure point? Big, patronizing smiles and the refrain, which is everyone’s “get out of jail free” card: “I’m glad they are finally doing something. You see, I see so much of this.” They were experienced, you see. They had been in the trenches. They had decades of “seeing it first hand.” If I knew what they knew, they implied, I would champion these new recommendations because their knowledge is vast, and their insight is keen. I am just the bleeding heart do-gooder who doesn’t understand how things really are. They have, after all, seen so much of this. For what it’s worth, I worked for years in emergency departments. I have also been a hospitalist. I have done what they have done and dealt with the same crap they have. Do any of them practice evidence-based pain management? They do not. Do they make even the slightest effort to treat substance use disorder or even show compassion to those who demonstrate signs of it? Don’t make me laugh. So here it is, a few years later, as I bat cleanup for this particular set of recommendations. Decompensated adults who are sick every day because all those physicians had no idea how to taper them humanely and responsibly off of their controlled meds and just did it anyway? I see so much of this. I see people who arrive in my office with uncontrolled pain and insane polypharmacy because instead of keeping their patient on one or two opioids, their provider decided to swap them to one SNRI, one GABA agonist, ketamine, bupropion, and everything else but gasoline? I see so much of this. The 103,000 hospitalizations and 16,500 fatalities secondary to NSAIDs that happen annually, yet everyone believes that they are much safer than opioids. I see so much of this. Elders who have increased falls, decreased independence, and come to my office in tears because their other doctor literally scolded them for wanting the pain meds that used to be effective but were taken from them through no misdeed of their own? I see so much of this. People without a substance use disorder, who nonetheless show up at my methadone clinic because no one else will manage them after their long-term prescription was discontinued? I see so much of this. The increased rate of overdose in my state the year this policy rolled out and every year since. Because when you change the supply but not the demand, you create an influx of fentanyl and heroin? I see so much of this. I have a wall in my office that is covered with pictures of people whom I knew personally who died related to their substance use disorder. You might say I see so much of this. Source
