The battle between advocates for pain treatment with opioids and advocates for cutting down on opioid prescribing has been brewing for months but reached a breaking point this fall when the federal Centers for Disease Control and Prevention (CDC) briefly released draft guidelines to reduce opioid abuse.

Many pain management experts “see the guidelines as being nothing short of misguided,” Pain Medicine News reported in its November issue, published online November 5. “In their attempt to mitigate the real risks and dangers of addiction, critics allege that the new guidelines will cause real harm to a significant subset of chronic pain patients for whom opioids do not pose a threat, and who often do not have any other options to treat their pain,” the publication reported. “These perceptions are fueled by the fact that the draft guidelines were made public for only an hour and a half in mid-September, during a webinar, followed by a 48-hour window in which to send comments by email; as well as by the fact that the webinar in question was well attended by nonprofits focused on fighting addiction, insurers and pharmacies, and poorly attended by advocates of chronic pain patients.”

PROP

In particular, Physicians for Responsible Opioid Prescribing (PROP), headed by Andrew Kolodny, M.D., has drawn particular anger from the pain advocates. Kolodny, who is also medical director of Phoenix House, is passionate about preventing overprescribing of opioids. He has taken the Obama administration to task for not doing enough to prevent this. Hardly anti-medication — Kolodny is a big proponent of buprenorphine for the treatment of opioid use disorders — he nevertheless is a lightning rod for the pain community’s anger at being denied what they say are the only medications that help. He is frequently interviewed by ADAW and strongly believes in saving people from overdoses.

“The focus should not be on whether opioids should be used or not — the focus should be on what a person in pain needs,” said Lynn R. Webster, M.D., a past president of the American Academy of Pain Medicine, and a Pain Medicine News editorial board member. “There should be a risk-benefit analysis for every treatment, and that’s what should decide whether opioids are prescribed or not. You can’t paint every person with the same brush.” Webster told ADAW that he wonders how many prescription opioid overdoses are actually in patients who “couldn’t stand the pain anymore and took too much” (see ADAW, Sept. 17, 2012). Very little is known about the circumstances or characteristics of prescription overdose fatalities. However, the CDC’s Leonard J. Paulozzi, M.D., told ADAW this spring that stemming the flow of prescription opioids now will prevent future heroin overdoses (see ADAW, May 4).

Two crises: opioid addiction and pain

There are two national crises, Webster told Pain Medicine News. The CDC is addressing one: opioid addiction. But the other — people in pain — needs to be addressed as well, he said.

Webster also criticized the CDC for allowing payers to help draft the guidelines.

“That would be equivalent to having pharmaceutical companies making opioid guidelines,” he said. “I would hope the CDC would be above that, that they’d be most interested in helping patients, whether they have the disease of addiction or the disease of chronic pain.”

Jeffrey Fudin, Pharm.D., founder and chair of Professionals for Rational Opioid Monitoring and Pharmacotherapy, told Pain Medicine News that “the pain community is outraged.” However, he said, many pain patients are “indigent” and “don’t have the wherewithal to rise up against a government agency, or a group like PROP, that’s working 24/7 trying to take opioids away from patients in need.”

Fudin criticized the “secret way” in which the CDC is conducting the development of the guidelines. “One group that was on the CDC webinar was CVS — they own a huge, huge PBM [pharmacy benefit manager],” he said. “Don’t you think that’s a conflict of interest? They don’t want to pay for long-term extended-release opioids. It’d cost them a fortune.”

And giving the chronic pain community only 48 hours to respond to the guidelines was “cruel,” said Fudin. “I’m just disappointed in the CDC,” he concluded. “What they did was ethically, medically, professionally and morally wrong.”

Funding bias?

Meanwhile, the pain advocates are being accused of being funded by pharmaceutical companies that make opioids. Longtime reporter Ed Silverman, who covers the pharmaceutical industry in his Pharmalot blog, wrote an editorial November 10 in STATS headlined “CDC is right to limit opioids. Don’t let pharma manipulate the process.” Silverman quoted David Juurlink, M.D., a clinical pharmacologist at the Sunnybrook Health Sciences Centre and a member of PROP, as saying, “The criticism is hollow and comes from people who are heavily conflicted.”

In fact, virtually all not-for-profits in the field are funded to some extent by the pharmaceutical industry: the National Council for Behavioral Health, the American Association for the Treatment of Opioid Dependence, the National Alliance on Mental Illness and Community Anti-Drug Coalitions of America. These organizations cannot raise money from people with addictions or mental illness.

Pain patients can be viewed as similar to patients with addiction in this battle: pawns in the chess game between the pharmaceutical companies and the addiction prevention and treatment field. Or they can be viewed as patients who don’t have a voice and whose only representation is the people who treat them.

The bottom line: if the people who are dependent on prescribed opioids are cut off from them, they will need treatment, or they will seek opioids on the street to avert withdrawal. In many communities, the opioid of choice is now heroin, and the vast majority of patients in treatment for heroin addiction started with prescription opioids. Whether that start came from a prescription pad or from diverted medication bought in the street or stolen from a medicine cabinet is still an unanswered question. Meanwhile, the CDC plans to release the guidelines in January.