Thrown Off the Pendulum

by Mordecai Potash, MD

In the two years that have passed since the CDC Opioid Guideline was released, many pain management thought leaders have conceptualized this guideline as a pendulum that was to swing patient care from an extreme of opioid permissiveness to a more thoughtful middle-ground of opioid allowance within limitations. That middle ground was supposed to permit opioid prescribing in chronic pain for well-selected and well vetted patients whose dosing is within reasonable limits. After all, the CDC guideline’s authors made it clear that they were not trying to create a new standard of care in pain management, but instead give clinicians recommendations to make their own clinical approaches to pain management treatments safer and more effective.

However, there are several recent publications to suggest that – far from finding a balanced middle ground – the pendulum has swung abruptly in the opposite direction with patients being thrown off long-established opioid treatments because of providers’ stark fears and frustrations.

In a ‘Perspective’ published in the New England Journal of Medicine, Dr. George Comerci and his colleagues at the University of New Mexico reported that their interdisciplinary pain service has been inundated with patients who were compliant with their pain medicine treatment for years or decades but had their lives thrown into turmoil when their doctors abruptly adopted strict “no opioid” policies [1]. The article also pointed out that even when physicians are willing to continue to prescribe opioids for stable patients, health insurance companies require a mountain of prior authorization paperwork to be filled out for these patients.

In my own outpatient practice, I have encountered – and spent countless hours – filling out these cumbersome prior authorization forms. By taking between 45 minutes to one hour per form, what the insurance companies label as a tool to help the prescriber has instead become an onerous burden dissuading providers from continuing opioid treatment.

In another article published in Reason Magazine, Jacob Sullum and his colleagues wrote an amazingly comprehensive description of the many facets of our country’s current opioid crisis [2]. They pointed out that although opioid-containing pain medications has led to misuse or addiction issues in some chronic pain patients, this has not happened nearly as frequently as portrayed in the media. Mr. Sullum pointed to the 2014 results of a survey from the National Survey on Drug Use and Health that suggested that a little more than 2% of chronic pain patients end up misusing their pain medications to the point of substance use disorder. This number is far less than is quoted by Governor Chris Christie, the point-man of the Trump Administration on the opioid crisis. The article also points out that opioid prescriptions have been dropping since 2010, even as opioid abuse has been sky-rocketing with heroin and black-market fentanyl which account for the spike in opioid abuse – not prescription medications.

The Reason Magazine article makes it clear there is some relationship between permissive opioid prescribing and the rate of national opioid abuse. But that the relationship is not a straight-forward one and often depends on other factors such as educational attainment and employment options.

Dr. Sanford Silverman does an outstanding job expanding on these ideas in his newly published article “CDC Guidelines: Be Careful What You Wish For” [3]. Dr. Silverman points out that we are really dealing with two epidemics when we look at what is being called the opioid crisis – there is the epidemic of prescription opioid abuse which has been declining since 2010 and a separate epidemic of illicit heroin, fentanyl, and other illicit opioids which has been increasing dramatically since 2010.

Dr. Silverman points out that the strict regulatory changes affecting states like Maine and Rhode Island – as well as changes in major health insurers like CVS Caremark – will decrease precipitously the number of opioid prescriptions being written for patients but will likely do nothing to combat opioid overdose deaths in the state. What is needed is easily accessible medication-assisted treatment for patients whether they developed addiction from illicit drug use or prescription use. So far, medication assisted treatment remains out of reach for most patients.

Dr. Silverman also points out that the CDC Guidelines were primarily geared for helping the primary care provider dealing with acute pain complaints. This type of patient is very different that the type of patients that we pain clinicians usually encounter. Our typical patient has seen several, if not dozens, of previous pain management providers with mixed success and are often coming to us already on high dose opioid therapy (what Dr. Silverman calls “legacy patients”). If we are to follow the CDC Guideline strictly, we are supposed to reduce the dose of pain medications to 90 morphine milligram equivalents per day. But, for many of these patients, this is not a realistic goal and would present real harm to the patient if attempted. The real question is what can we do for these patients that acknowledges their current treatment regime and response to that treatment while also acknowledging changing standards of care in opioid-based therapy for chronic pain.

Well, I am delighted to tell you that our September annual conference will go a long way in answering the conundrums raised by these three articles – with our conference theme on ‘Balanced Approaches to Acute and Chronic Pain’.

Dr. Silverman will be speaking on the CDC Guideline and the points he raises in his article. Our conference will also feature Keith C. Raziano, M.D., Physicians Pain and Rehab, Sandy Springs, GA, who will be speaking on Maximizing Functional Outcome and Minimizing Chronic Pain. The popular author and orthopedist David A. Hanscom, MD, at the Swedish Neuroscience Institute will be speaking on Solving Chronic Pain with a Self-directed Structured Approach.

As if that isn’t enough, we will also host talks on several other areas including Catastrophic Injury Across the Continuum, and Advanced Techniques in Neuromodulation. Taken together, we have assembled an array of nationally prominent speakers presenting on exciting and practice-relevant topics.

So, I hope that you keep fighting the good fight for your patients, who I am sure appreciate everything that you do for them. I also hope that you plan to join us from September 21st to 23rd at the Sheraton Atlanta Hotel to recharge your batteries, reconnect with colleagues, and learn how excellence in pain management is still achievable even during these trying times!

[1] G Comerci, J Katzman, D Duhigg. Perspective. Controlling the Swing of the Opioid Pendulum. New England Journal of Medicine, published 02/22/2018 and accessed at

[2] Jacob Sullum. America’s War on Pain Pills Is Killing Addicts and Leaving Patients in Agony. Reason Magazine, April 2018 issue. Accessed at

[3] Sanford M Silverman. CDC Guidelines: Be Careful What You Wish For. Interventional Pain Management Reports. Volume 2, Number 1, Pages 1-8. Accessed at