Clearly there are always unintended consequences

by U.S. Medicine

February 4, 2016

Clearly there are always unintended consequences of any legislative or regulatory act that’s taken in the heat of battle.” — Richard Grasso

Editor-In-Chief, Chester "Trip" Buckenmaier III, MD,  COL (ret.), MC, USA

Editor-In-Chief,
Chester “Trip” Buckenmaier III, MD,
COL (ret.), MC, USA

Richard “Dick” Grasso was chairman and chief executive of the New York Stock Exchange from 1995 to 2003 and is credited for his efforts to restart the Exchange following the September 11, 2001, terrorist attacks. Though his quote on unintended consequences was directed at financial systems, I believe it is germane to recent efforts by the executive branch of our government and the Centers for Disease Control and Prevention (CDC) concerning the prescription opioid epidemic currently raging in this country.

In 2013, drug overdose was the leading cause of injury death, surpassing motor vehicle accidents.1 Shockingly, the majority of these overdose deaths were related to prescription opioid pain medications, often in combination with benzodiazepines.2 Clearly, there is a growing problem with prescription pain medication use and the medical community’s response to patients with pain. Federal medicine has not been immune to this crisis, which was outlined along with recommendations in the “DoD Pain Task Force Report — May 2010.”

The federal government has responded to this crisis, first through a “Presidential Memorandum — Addressing Prescription Drug Abuse and Heroin Use” in October 20153 that was quickly followed by the CDC’s recently released draft “Guideline for Prescribing Opioids for Chronic Pain.”4 I believe the CDC’s efforts to provide clinicians guidelines for prescribing pain medications is laudable but incomplete, because the root cause of Americans’ poorly managed pain is not addressed. This omission is surprising, given the CDC’s mission in public health, and might reflect the influence of a panel focused on opioid misuse, not the well-being of the very large population of Americans suffering from chronic pain and its consequences, such as disability, mental health disorders — including suicide — and deterioration in social and occupational functioning.

Multiple groups have likewise expressed concerns over the relatively closed process used by the CDC, since key pain experts and organizations were not involved materially in developing the guidelines. Perhaps most concerning is the omission in the guidelines of increasing general provider pain management education.

It is unlikely that we will ever overcome the epidemic of opioid overuse and abuse without adequately addressing pain management education and training for clinicians. Part of this educational effort must include patients to help the public understand the dangers of opioid medications and integrative medicine options for managing pain. Failure to address the larger issue of pain management in Americans, while focusing on the symptom of this issue, prescription opioid misuse, abuse and diversion, will likely result in a host of new unintended issues. In a recent conversation with a prominent pain specialist, the situation was likened to managing a cholera outbreak in the modern era by just treating cholera patients and never bothering to inspect the community well or water source.

To be clear, I do not have a problem with the CDC responding to the issue of prescription opioid abuse that has devastated so many lives and families. On the contrary, this response is long overdue. My concern is this effort will be seen as a President George W. Bush style “mission accomplished” banner, proclaiming a fix of the opioid problem while ignoring the ongoing greater issue of poorly managed pain.

These guidelines will be seen as mandates within the federal system and will have far reaching consequences for many patients who depend on these medications, under supervision of a pain specialist, for functional life. Furthermore, the guidelines assume an intact and functional system for managing acute and chronic pain with non-pharmacologic and non-opioid options which is not necessarily the case.

Significant adjustment to reimbursement and prioritization of pain management services will be required to establish this pain care infrastructure in both primary and specialty care. It is certainly worthwhile and straightforward to respond to the easily observable opioid crisis confronting the country. President Barack Obama and the CDC are to be congratulated for this effort. It would be terribly foolish, though, to believe this endeavor will solve the problem without addressing the larger, more subtle issue of poorly managed pain.

These guidelines are a good first step but the overall mission of dealing with the pain problem in this country has only just begun with the recently released National Pain Strategy.5 The release of the CDC guidelines has generated considerable comment and criticism from many individuals, organizations, and groups concerned about unintended consequences of this federal action.4 It is my hope that the CDC will see these comments and concerns not as an attack but an opportunity to expand this effort and include the pain management community in resolving the larger issue of poorly managed pain in America.

I choose to remain optimistic for federal medicine in this regard. Since the DoD Pain Task Force document was released there has been significant collaboration and coordination between the VA and DoD. This has resulted in numerous programs and efforts to establish a federal medicine system of pain care. Federal medicine has truly demonstrated leadership for the country in this regard. What has been missing from this effort is prioritization of these pain efforts by federal medicine leaders within the fiscally constrained environment presently in existence. Perhaps the guidelines will refocus leadership and allow a broader perspective of the disease problem of pain in America as opposed to just its symptom of opioid overuse.

  1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2014) Available from URL: http://www.cdc.gov/injury/wisqars/fatal.html.
  2. Centers for Disease Control and Prevention. National Vital Statistics System mortality data. (2015) Available from URL:http://www.cdc.gov/nchs/deaths.htm.
  3. The White House – President Barack Obama. Presidential Memorandum – Addressing Prescription Drug Abuse and Heroin Use (2015). Available from URL: https://www.whitehouse.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-and-heroin
  4. Centers for Disease Control and Prevention. Injury Prevention & Control: Prescription Drug Overdose (2015). Available from URL: http://www.cdc.gov/drugoverdose/prescribing/guideline.html
  5. The Interagency Pain Research Coordinating Committee. (2015) Available from URL: http://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm

 

 


2 Comments

  • Jeff Alden says:

    Some of this goes back to the “release the opiates” moment in the late 2000’s when congressional guidelines were to treat all pain aggressively and the silly notion that somehow pain immunized you from addiction risk. I stopped prescribing opiates altogether so as not to be pressured into doing it wrong.

  • Jeff Alden says:

    Some of this goes back to the “release the opiates” moment in the late 2000’s when congressional guidelines were to treat all pain aggressively and the silly notion that somehow pain immunized you from addiction risk. I stopped prescribing opiates altogether so as not to be pressured into doing it wrong.


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