CDC Opioid Guidelines Could Cause Problems for VA Patients, Clinicians

Congress Is Forcing VA to Comply With ‘Voluntary’ Document

By Annette M. Boyle

ATLANTA — VA clinicians and their patients might find themselves in a difficult position related to proposed opioid prescribing guidelines from the national Centers for Disease Control and Prevention (CDC).

The CDC did a limited initial release of the guidelines in September with a two-day comment period and was immediately criticized for placing greater emphasis on reducing opioid abuse than relieving pain.

After the document was published in the Federal Register in December and controversy continued, the CDC announced it was reopening a 30-day comment period, which ended in mid-January. The primary concerns were whether the guidelines had a strong enough evidence basis and that the initial panel included too many experts in the substance abuse field and too few in the pain management area.

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In whatever form the guidelines end up, however, the VA will have to follow them because of a requirement of the agency’s spending bill that went into law late last year.

More than 4,300 comments were received before the January 13 deadline. The National institute of Health’s Interagency Pain Research Coordinating Committee, which includes representatives of the VA and DoD as well as the Food and Drug Administration, Agency for Healthcare Research and Quality and the CDC, had expressed concerns about the low quality of evidence used as the basis for strong recommendations in the guidelines even before the comment period.

In response to the broad-based concerns, the CDC’s National Center for Injury Prevention and Control’s Board of Scientific Counselors appointed a 10-person expert review panel, which includes Erin Krebs, MD, MPH, an investigator with the VA’s Center for Chronic Disease Outcomes Research in Minneapolis. She joins other national leaders in pain, geriatrics, public health, pharmacy, primary care and emergency medicine.

The appointment of Krebs might be the best chance for the 50% of male veterans and 70% of female veterans who experience chronic pain – as well as the physicians who treat them – to gain a voice in the revised guidelines.

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Comments (15)

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  1. Joe Accordino says:

    Due to avascular necrosis of the jaw I became unable to work after ten years and 30 surgeries. My surgeon and later my pain management doctor prescribed opioids which allowed me to work again for 7 more years while undergoing 3o more surgeries.Now I cannot find a doctor who will prescribe any pain medication.I will have to go on disability,lay around at home and if denied dissability,well there is alot of fear and uncertainty.These were not recreational drugs.To deny sick people medication is disgusting and immoral.

  2. James A. Davis says:

    I am a 100% service-connected disabled veteran, and have had surgeries and chronic issues in the passed for which I’ve required opioid treatment. If Dr. Zeitzew is the same one I knew at VAMCLA, I remember him well, and his own care for the patient’s pain, after he (or one of his staff) had to reattach the distal end of my right quadriceps to the kneecap in 2004.

    Judging from what I am seeing now, at VAMC Lexington, KY, I think the doctors are hamstrung from providing the necessary pain medication, whether for acute or chronic cases.

    That said, I think ANY process/substance which alleviates the pain needs to be considered. I’ve been lucky to have gotten a great deal of pain relief from acupuncture in the past year for my slowly-deteriorating spine, so much so that I’m going to be discussing the next planned “pain management” steroidal injection, due next month, with the doctor.

    As a patient, I am less concerned about unproven or alternative techniques than I am my doctor’s ability to take care of me.

  3. Mike Perry says:

    I am a 100% disabled Vet due to a Parachuting Accident while on Active Duty which broke my back in 3 places. I developed a disease called Adhesive Arachnoiditis directly related to the injuries I had received.

    The disease is characterized by unrelenting intractable pain with no know cure. For me, after trying every other pain reliever available to the VA and outside the VA, the synthetic opiod Fentanyl is the only drug, in any category, to give me partial relief from the chronic pain.

    It is obvious to me and my pain Dr., Dr. Forest Tennant, that the make up of the CDC’s panel had very little or no representation from the millions of chronic pain sufferers who’s only chance at a somewhat normal life is through the use of opiod pain relievers. Although there are a number of people who for the most part do not follow their medication labels, or mix their prescription medications with alcohol and other illegal substances resulting in overdose, there are millions more people who live in a world of unbelievable pain on a daily basis who’s only respite is from the prescription of opiod drugs.

    It would be a travesty for the CDC to draw up the guidelines, which will impact millions of lives, using a panel devoid of any representation for the millions of people dependent on these drugs for relief of unbearable pain. I know, because I’m one of those people.

    Please, Please consider not only my suffering, but the millions of other people, in and out of the VA, who’s very basis for a somewhat normal life rests in the use of opiod drugs to contol unbearable pain. Believe me when I say that there is no better drug available for intractable pain than opiods. Don’t remove these tools from the Dr.’s who treat intractable pain patients on a regular basis. They know best what works and doesn’t work and their voices, along with ours, the millions of people relying on these drugs to allow us just to get out of bed, need to be heard.

    And, this is not only true of the CDC, but in every case in which laws are written to control the Dr.’s ability to prescribe what their patients need.

    Mike Perry

  4. Jeff H says:

    I thought the objective of doctors was to provide care for a patient? Doctors practice medicine. Every person is different. The doctor and patient should be able to figure out what is best for the patient. The quality of life is determined by the patient, not the doctor. Regulators and administrators should not be determining guidelines for patients that they have no interaction with. The doctors interact with the patients. That is where the decisions should be made.

    • Jim Reynolds says:

      Doctors no longer treat patients in so much as they try to protect their medical lic. first by complying with the dea ,cdc ect. Dogs and Cats are treated more humanely than human . The pain management Doctor at the VA told me this week they were going to cut or discontinue my meds . He also said the cdc had gone to far , suicides are way up the US government is a cruel swamp of vipers ! Who gains here ? Ex dea agents running treatment centers and bringing in heroin on the side from Mexico , Dr. A. K is so full of crap one can only hope he burns in hell , as he is behind the cdc closed cooked studies , millions will die because of one him and the Senator whos son died from a overdose , Dr. Andrew K P house. I’m done being pushed around by idiots who are corrupt and lining their filthy pockets . Someone needs to do the world a favor and personally visit the good Doctor

  5. J Falk says:

    This is going to make it hard to raise a volunteer amy. Who would sign up knowing they could be hit by an IAD and sent home wjth no pain meds? i guess Obama has just made sure there won’t be boots on the ground long after he’s gone.

    • Silent Sentinel says:

      Obama doesn’t run the CDC, Reagan declared the “war on drugs” in the ’80’s, this is the trickle down, to criminalize even veterans with legit, urgent needs & give them no alternative but suicide, then label them ‘crazy’. That’s what’s criminal!

  6. Ronnie Patterson says:

    Many veterans have conditions which can be treated by opioid use only, due to allergies and intolerance to other drugs. I am unable to take several different drugs due to allergic reactions, or damage to an ulcerated stomach. I have been prescribed hydrocodone for treatment of extreme pain of migraine headaches. I have been taken off prescriptions of ibuprofen, aspirin, and several other medications due to allergic reactions.

    I have used other medications in attempt to reduce migraine pain or used as a prophylactic against the migraines. Most of the treatments are ineffective, or counter intuitive to treatment for the migraines. One in particular {imatrex} causes migraines to become even more painful. Hydrocodone has been the only drug that has been able to control the pain, short of going to my PCP for an injection for the pain.

    I understand the drive to reduce the number of veterans on opioid prescriptions; however, there can never be a “one size fits all” answer to this problem. The most productive way to deal with it is to trust the physicians in the system to place those of us who are long term opioid prescribes on a pain management program and monitor us.

  7. Teresa says:

    I feel that the sick are being treated poorly because they are sick. Chronic pain is not just extremely painful it is also mind boggling. It effects your ability to think straight. If chronic pain is NOT treated properly it leads to other problems, mainly depression. The feeling of uselessness is not a joke it is real. If chronic pain was treated properly the depression may never occur which will in turn keep health care costs down. The problem is when it is not treated immediately and properly the other problems comes into play. It needs to be treated as a crutch to help you cope with and actually LIVE life, not overlooked or over prescribed. Not all meds are for everyone, each person is different. If the doctors were able to spend just 10 minutes minimum with a patient at every visit it would make such a huge difference. It would lead to help instead of making things worse. The doctors are getting a bad reputation because of these poor guidelines they have to follow. What happens when the doctors are no longer trusted? major epidemic then.

  8. pamela archer-beck says:

    It seems we, in the USA, frequently come from a reactionary place. While opiate abuse is certainly on the rise, asking persons with real pain to bear the burden of a culture ridden with substance abuse seems not only unfair, but inhumane and yes reactionary.

    Perhaps a wise culture would spend resources delving into the root cause of substance abuse and addressing that… (things like poverty, racism, sexual abuse etc etc) not a quick fix I know, but perhaps a smarter fix. Maybe, just maybe then we can begin to progress.

  9. Michelle Woznicki says:

    It’s now the latter portion of 2016 and I’m living the effects of the CDC report. A year ago I was receiving appropriate medical treatment under Veterans Choice. The CDC report ceased everyone’s opioids but it also ceased my medical care. The report recommends alternative treatments in lieu of pain medication. All veterans at my hospital have been flushed to the beginning reevaluating point. We now are to sit in classes and unlearn our pain. In my case that involves 6 months of driving 270 miles a day round trip to the VA Hospital. Next is physical therapy which I received a 1 year referral to my local area. The VA won’t tell them what’s wrong with me so I take in my MRI and they’re afraid to do anything as I’m in bad shape with a milieu of back conditions. Meanwhile, the VA dumbs down my condition and their doctor tries to say I only have a muscle strain which is reflective of a diagnosis from the military 25 years earlier. This way the VA doctor doesn’t have to expend so much energy on me. My previous medical treatment, prior to the CDC report, that had me walking were steroid injections, epidurals, and nerve ablation. Now I have nothing and am in constant pain, find it extremely difficult to walk and its day by day living. Is this what the CDC thinks is good? Pull pain pills and appropriate medical care? That’s what they did to me and it was medical care that worked. Now I have nothing but accusations I’m a difficult patient for refusing to run in the circles the Veterans Administration is doling out.

    • Silent Sentinel says:

      I’m in the same situation, I’m a 100% service-connected disabled vet. The San Diego VA had been giving me opiates due to chronic, intractable pain for 12yrs, now all of a sudden they’re pulling them, telling me lies about why, trying to blame me when I’ve never abused them or done anything wrong!

      Due to allergies, an ulcer, & a disease called MG, I can’t take anything else, yet they’re actually suggesting a patch I’m allergic to & also says on the warnings “not for MG patients”! They’re literally recommending something that will actually kill me, while claiming that the med I’ve tolerated very well for 4yrs is somehow now the immediate danger to my life! Thank goodness my parents & I did our research!

      I can’t get out of my bed/home regularly enough even with opiates anymore to try alternatives AGAIN, tho I have tried several in the past at my own expense! I haven’t even been able to date since my divorce in ’06!

      Luckily I also have SSDI, Medicare HMO, which I had to get because the untreated MG would’ve killed me years ago due to the VA ignoring it, which they’re doing because each treatment is about $35,000, and I need them monthly for life, so they just made up a story that I was lying about my disease! Yeah, cuz I just LOVE paying out thousands of $ ea yr in co-pays & having a port surgically implanted in my chest-right? BTW, I had a TS clearance in the Navy! I learned to mistrust them long ago. The “Choice” program even lied to me to get out of sending me to neurology! As an agency, it’s as corrupt as they come!

      Anyway, my point is that, if you haven’t already done so, apply for Social Security Disability & try to get covered that way, or w some other insurance. Now that I’m being cut off of opiates abruptly & W/O any honest explanation, follow-up or alternative available to me, I plan on exposing the VA’s failures & criminal neglect of me (& resume opiates thru my HMO, so the PAIN doesn’t kill me). I hope other vets do the same. We deserve so much better! Good luck to all other vets being mistreated!

  10. Richard A. Lawhern, Ph.D. says:

    I have supported chronic pain patients for over 21 years as a webmaster, moderator and research analyst in multiple online peer to peer forums. Though I am not a licensed physician, I write extensively on the subject of opioid policy, as a subject matter expert. A google search on “Richard Lawhern” plus “Face Facts” will immediately call up an archive of my published work, including articles in the Journal of Medicine of the US National College of Physicians.

    Along with hundreds of medical professionals, I advocate for the immediate withdrawal of the March 2016 CDC opioid prescription guidelines. As written, the CDC standard is outright fraudulent and deeply dangerous, with a clear record of cherry-picking research to support a political agenda of anti-opioid advocates.

    More fundamentally, the guidelines ignore well established medical science on the metabolism of opioids and other pain-relieving medications. Millions of people in the US are either hyper-metabolizers or poor metabolizers of opioids, anti-depressants, or anti-seizure drugs, due to polymorphism of genes which regulate the breakdown of drugs in the liver before passage across the blood-brain barrier.

    Enforcement of the 90 Morphine Milligram Equivalent Daily Dose limit is leaving hundreds of thousands of pain patients under-medicated and exposed to unsupervised opioid withdrawal with risk of cardiac arrest. The great majority of these patients are at NO risk of opioid abuse disorder.

    Moreover, there is ample evidence that the so-called “opioid epidemic” was never created by medically prescribed drugs, regardless of liberalization of prescribing policy in the 1990s. Authorities in addiction medicine acknowledge that 90% of drug addicts first encounter opioids and other intoxicants as adolescents — at a time with only a tiny minority have medical encounters that would result in prescription of opioids. A Cochrane Review of 2010 reinforces this understanding by finding that fewer than 1% of previously opioid-naive patients in multiple published studies were later found to have been treated for opioid use disorder.

    Finally, we can lay much of the death and destruction of the opioid crisis at the feet of the FDA itself. In the three years after they forced reformulation of OxyContin in “abuse resistant” form, prescriptions for this medication dropped by two thirds while heroin-related deaths doubled. The relationship between these stats is crystal clear: addicts who had been maintained safely on Oxy went into the streets.

    The only ethical way forward from the present mess is immediate repeal and rewriting of the CDC opioid guidelines and repeal of ALL State and Federal laws which enshrine them as standards of medical practice.

  11. Paula says:

    Just came from the VA in Johnson City, Tn today and let it be known, we veterans, have got to start raising hell with the VA,Congress and the Senate!!!!!!!! I have 5 different issues with my back, I have been taking tramadol before it was considered a narcotic. My NP never looked at my medical records before starting my on coming off my meds. I don’t drink, don’t do illegal drugs,never flunked a drug test and she said she was told to do it. Everyone get to your patient advocate and get your complaint on record, the advocate should give you paperwork to fill out, fill it out and the lead advocate will file with your VA. We need to come together and fight long and hard.

  12. john says:

    I have been taking the lowest dosage Hydrocodene and the lowest dosage Valium for over 40 years. Iam now 70. I have had two back surgeries and need another the VA will not do , due to the danger involved. I have had migraines and PTSD. through it all I have worked full time. Ran an overseas NGO for five years . I sit on the veterans and family council in my area and work with Vets in worse condition than me. I also have nerve damage in my feet. I am an ExPOW and through all this my Dr took my Valium away as it would hurt me. RIGHT now I have trouble walking , sitting and sleeping due to pain. I have had to quit what I due to stay sane. What happed to quality of life and having a say in my own life. Now I have had to apply for aid and attendance due not being able to drive. More money less life. Can’t seem to win. John

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