In March, 2016, the Centers for Disease Control published a monograph detailing that institution’s recommendations in regard to prescribing opioids to patients suffering from chronic non-cancer pain. The intended target audience was primary care physicians who were caring for opioid naïve patients (those not taking chronic opioids). It was issued as a response to the “opioid crisis” and “opioid epidemic” in which thousands of mainly young people across the US were dying from drug overdose. It was spearheaded by a group of addiction treatment doctors who were opposed to all chronic opioid use.
It contained many useful suggestions to help discourage abuse. It recommended trying non-opioid treatments first such as physical therapy, acupuncture, psychological treatments (such as Cognitive Behavioral Therapy), chiropractic, urine drug screening, pill counts, use of the State Prescription Monitoring Data Base, use of risk assessment tools, elimination of Benzodiazepines and other respiratory depressing medications. (These measures are all part of Kroll Care’s offerings and safeguards).
The guidelines included adoption of the premise that chronic opioid use is NOT EFFECTIVE IN TREATING CHRONIC PAIN. This assertion is based on a single reference in the bibliography. Because the CDC is a government agency, its official pronouncements are relied upon and taken as authoritative and unequivocal. (You can find references to articles directly refuting this position in the following:
- Benefits and Risks of Opioids in Arthritis Management
- Opioids for chronic pain: new evidence, new strategies, safe prescribing
- The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain
- Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects)
To my mind, the most harmful to chronic pain sufferers, is the adoption of “safe medication levels”. These are measured in “Daily Morphine Equivalents”, an artificial system based on weak assumptions of relative absolute strength of any medication compared with morphine. The methods establishing these conversions are based on flimsy evidence. Because the CDC set these limits of “safety”, insurers, medical institutions, government agencies at every level have set them as absolute limits rather than suggestive guidelines.
Medicare has announced that beginning January 1, 2019, the MAXIMUM amount of pain medication it will allow for beneficiaries will be less than 90 Daily Morphine Equivalents and the longest prescription will be 7 days.
The harm comes from ignoring the effects of opioid “tolerance” in defining “safety”. All opioids cause tolerance to occur when taken chronically. Simply put, as the body becomes used to the presence of the opioid, over time, the medication becomes less effective at that same dose. Over time it takes more medication to produce the earlier result. Tolerance also develops to most of the side effects of the opioid so that someone regularly taking 200 daily morphine equivalents will react with less danger to that dose than someone not taking opioids would. The CDC ignored tolerance when setting its limits. This is fine when treating patients who are new to opioid therapy but is untenable for the long term taker of opioid pain medicine.
The conversion factors have also been changed The conversion factor for Methadone has been changed recently by the CDC. It now increases with increasing dosages. Until recently the conversion factor was 3 by most authorities. Late 2017 conversion instructions from the CDC are listed below:
- Methadone 1-20 mg/day 4
- 21-40 mg/day 8
- 41-60 mg/day 10
- ≥ 61-80 mg/day 12
Utilizing the new conversion factors will make it impossible for patients receiving 30 mg or more daily to achieve less than 200 Daily Morphine Equivalents (ME) and if taken with other narcotics will never be less than 100 ME. I will continue to use 3 as the conversion factor
According to the CDC, any amount of Methadone greater than 20 mg per day, even in divided doses, is “excessive”. It should be noted that the average patient at a U.S. Government sanctioned Methadone Clinic receives between 150 and 200+ mg of methadone in a single daily dose. Even at the low end of 150 this is an ME of 1,800.
How are we supposed to trust this data? Even if we don’t subscribe to the new reality, we are bound by it. The future is bleak for our long term patients with years of accumulated tolerance. Even shifting to another opioid doesn’t solve the problem because of incomplete cross tolerance. That is partial tolerance to the new opioid based on exposure to the class of medications. While switching can reduce the daily morphine equivalent to some extent, tolerance to the new medication will already exist. Even if we don’t like or agree, the power holders have adopted these “guidelines” and the morphine equivalents and the conversions and they control payment for delivery of our services.
We will be working closely and humanely to help patients reach lower levels of opioids through use of Interventional procedures, psychological therapy, topical medications, substituting other opioids with less individual tolerance, and electronic devices. We will not lower the treatment to the point of insufficiency for individual pain management. We are working on implementing a waiver process for our patients who simply cannot tolerate excessive reductions. Stay tuned for future announcements.
Michael Kroll, M.D.
Medical Director and owner of Kroll Care
Georgia Licensed Pain Clinic #350