Opioid Policy Doesn’t Discriminate

The narrative of open prescriptions, which is assumed to have initiated the first wave of the opioid epidemic, has been wildly successful. So successful in fact that it’s hard to convince people of the suffocating regulations that weigh over the most modest of pain management choices. We have an idea of the opioid epidemic as a freewheeling monster putting entire communities to the torch. Tragically, we’ve lost sight of how opioids’ presence in society begins and ends in a doctor’s office between provider and patient.

It’s unfortunate that those conversations are influenced by priorities laid out by the Centers for Disease Control (CDC). The priorities expressed by such organizations are agnostic towards the underlying health concerns of the patient and the care put forward by their doctor. It’s dogmatic rather than informed. Every patient is assumed to be a single Morphine Milligram Equivalency (MME) away from a full-blown substance abuse disorder.

The nitty gritty of the phenomenon has gone widely unnoticed. The assumption has been that the CDC has been working hard to solve a problem, and institutional faith requires us to believe that our government would take precautions regarding the risks posed to vulnerable communities. Instead, what’s taken place is a sort of double speak where the CDC sought to address the concerns of every interest group while being indifferent to the costs of its broad declarations.

The meat of the dysfunction posed by the CDC’s 2016 guidelines regarding the prescribing of opioids was the seemingly arbitrary focus on a 90 MME threshold that denoted a higher risk of addiction. At first glance this seems totally reasonable. This threshold wasn’t a cut off. It asked doctors to closely monitor patients above 90 MME and to not rapidly raise their dose without good reason.

It’s important to keep in mind that during this period providers were told to put to bear far greater time and resources towards monitoring every opioid prescription, while also being under constant threat of investigation by regulatory boards and law enforcement. This is the environment wherein that arbitrary 90 MME threshold became deeply problematic.

It takes a lot of time to run a patient’s opioid prescription history. Specialty clinics like oncology write a lot of pain prescriptions, but they lack the funding and the staff to run what amounts, and is similar, to a background check on every patient. Also, it’s stressful to constantly keep in mind that every patient with chronic pain one attempts to treat could result in you losing your license at the the whim of a zealous DEA agent. Treating pain became a liability.

90 MME went from a measure of observation to a tool to deny care. To put this in perspective, 90 MME is a lot, but it’s not that much. It’s far more than the average person would ever see, but a person with serious intractable pain would certainly be above that benchmark (40 mg of Percocet = 60 MME, 60 mg of morphine sulfate ER = 60 MME, 50 mcg/hr Fentanyl Patch = about 120 MME. The 40 mg of Percocet would be paired with extended release morphine for 120 MME, and 50 mcg/hr Fentanyl patch is well over 90 before even factoring in breakthrough medication like Percocet). 90 MME became a disingenuous measure of addiction, and all other signs, or the lack thereof, were irrelevant once that point had been reached.

The lack of clarity as to what the CDC actually meant by 90 MME gave doctors a permission structure to force-taper, that is to reduce the dosage prescribed based solely on CDC guidelines, every patient above the line or find an excuse to fire them outright. Rapidly tapering down medications are never a good idea. Quickly removing the pain protection afforded by narcotics leaves the patient in a state of over sensitivity. This doesn’t only involve pain. The fight or flight anxiety produced by painful conditions is also amplified, leaving the patient in a worse state of health in the long term beyond the simply assumed increase in pain.

Providers also saw a way to exit the less-than-profitable medication, as opposed to procedural, pain management business. This is a difference of purely clinical specialty. There are no lucrative procedures to preform. It involves spending ten minutes with a patient and giving them their prescriptions. In contrast, interventional pain management is immensely profitable. Epidural injections and ablations are preformed very quickly in an out-patient setting. They bring in a lot of money for clinics and hospitals and the providers who preform them are highly paid. Crucially, these are the the same clinics that would treat complicated patients with intractable pain above the 90 MME threshold. Instead of offering protection they would enforce their pain contract with such scrutiny that it was impossible to always stay above board and the first infraction would result in letting the patient go with the black mark of being fired by a pain management clinic.

This didn’t end with doctors. State regulators defaulted to the 90 MME when deciding what Medicaid would cover, subjecting the poorest populations to unusually strict pain management regulations. DEA investigators saw going above this line as a de facto expression of guilt without ever engaging in the health realities of patients.

The entirety of our public health apparatus was turned against patients with painful chronic illnesses, and the effects have been heartbreaking. It’s not hard to find story after story of people who were blindsided by this gravitational change. It didn’t matter if the patient had spent years on the same medication that worked and never filled early. The threat to their stability was external and out of their control. For the chronically ill, adjusting to uncontrollable situations was a simple feature of their illness, but this attack appeared to be coming from those whom they trusted for care

Many patients went from being functional with their medication regimes to being totally disabled and unable to work. Others took more drastic action: Rather than live with the hopelessness of unceasing pain and the constant drama of adversarial healthcare visits they took their own lives.

The uproar over the guidelines from the pain management community was deafening. For three years patients and pain doctors begged the CDC to issue a clarification. People were losing their livelihoods and their lives, but the response from the CDC was total silence. The ask was modest. Advocates only wanted the CDC to clarify the 90 MME threshold to stop providers from denying care and to stop regulators from acting capriciously, but there is no social clout in the chronic illness community. They had no say in their own care and were met with contempt when they displayed any will to do so.

However, opioid policy doesn’t discriminate. It was only a matter of time before it started to affect the people who the CDC would listen to. In 2019 John Heubusch, president of the Ronald Reagan Foundation, wrote an op-ed in the Washington Post that detailed how the CDC’s guidelines had negatively affected his life. Shortly thereafter, more voices critical of the CDC started to appear in major outlets. It was only then that the CDC issued a modest clarification.

In the present everyone is aquatinted with the pop-psychologizing and broad double speak of our public health organizations, however; long before Covid and Monkey Pox, this attitude was directed acutely at the too-often-invisible chronic illness community. They saw the CDC sit by while their own guidelines (by their own admission) were grossly misinterpreted. The broader public of medical opioid users were not their base. The CDC sat idly by as countless patients begged for help, but acted quickly and decisively the moment prominent patients with access to major opinion pages voiced concern. The serious disrespect shown to the ordinary patients who depended on them left too many lives fractured and ruined.

It’s easy to get swept up in phenomenal frenzy when events like the opioid overdose epidemic reach the zeitgeist. We lose sight of the fact that these aren’t abstract figures. In the midst of the chaotic swirl are actual people, and in the case of health care decisions these are people who make up some of our most vulnerable citizens who had rare and valuable support yanked from beneath their feet. Cries for remedy went unheard. When those depending on opioid pain medication looked up and asked for help our collective medical establishment looked down and said “no”.