Amid a reckoning over opioids, a doctor crusades for caution in cutting back.
About four years ago, Dr. Stefan Kertesz started hearing that patients who had been taking opioid painkillers for years were being taken off their medications. Sometimes it was an aggressive reduction they weren’t on board with, sometimes it was all at once. Clinicians told patients they no longer felt comfortable treating them.
Kertesz, a primary care physician who also specializes in addiction medicine, had not spent his career investigating long-term opioid use or chronic pain. But he grew concerned by the medical community’s efforts to regain control over prescribing patterns after years of lax distribution. Limiting prescriptions for new patients had clear benefits, he thought, but he wondered about the results of reductions among “legacy patients.” Their outcomes weren’t being tracked.
Now, Kertesz is a leading advocate against policies that call for aggressive reductions in long-term opioid prescriptions or have resulted in forced cutbacks. He argues that well-intentioned initiatives to avoid the mistakes of the past have introduced new problems. He’s warned that clinicians’ decisions are destabilizing patients’ lives and leaving them in pain — and in some cases could drive patients to obtain opioids illicitly or even take their lives.
“I think I’m particularly provoked by situations where harm is done in the name of helping,” Kertesz said. “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”
It’s a case that Kertesz, 52, has tried to make with nuance and precision, bounded by an emphasis on the history of overprescribing and the benefits of tapering for patients for whom it works. But against a backdrop of tens of thousands of opioid overdose deaths each year and an ongoing reckoning about the roots of the opioid addiction crisis, it’s the dialectical equivalent of pinning the tail on a bucking bronco. Kertesz’s critics have questioned his motives. He’s heard he’s been called “the candyman.” (...)
Opioid prescribing has been declining since 2012, though levels remain higher than they were two decades ago. Today, depending on the estimate, anywhere from 8 million to 18 million Americans take opioids for chronic pain.
The interest in reducing their dosages is predicated in part on efforts to minimize patients’ risk of overdose and addiction. But there are other considerations. Enduring opioid use makes people more sensitive to pain, many experts believe. Opioid use has also been associated with anxiety, depression, and other health issues.
Plus, as people become dependent, the drugs might just be staving off symptoms of withdrawal that would come without another dose, rather than treating the original source of pain.
In short, experts say, long-term opioid use is not good medicine.
Kertesz, who is also a professor at the University of Alabama at Birmingham School of Medicine, agrees with all of that. But he believes that lowering dosages will hurt some patients who are leading functional lives on opioids, and that top-down strategies won’t protect them.
So, in 2015, when the Centers for Disease Control and Prevention proposed prescribing guidelines for primary care clinicians treating chronic pain, Kertesz grew nervous.
The guidelines, a set of measured recommendations finalized in March 2016, suggested clinicians try other therapies for pain before moving to opioids and prescribe only the lowest effective dose and duration of the drugs. (The guidelines do not apply to end-of-life or cancer care.) For patients on high doses, the guidelines said, “If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.”
“Our day-to-day practice aligns with nearly all principles laid out in the guideline,” Kertesz wrote in a comment he submitted on the draft. But he cautioned the voluntary recommendations could be implemented too stringently by others.
“This is a guideline like no other … its guidance will affect the immediate well-being of millions of Americans with chronic pain,” he wrote.
After the release of the guidelines, Kertesz started seeing ripple effects. In early 2017, federal officials unveiled a Medicare proposal that would have blocked prescriptions higher than 90 MME without a special review. Around the same time, the National Committee for Quality Assurance considered docking clinicians’ scores if they had patients on high doses for long periods.
Kertesz, other experts, and some medical societies protested such proposals, contending they invoked the CDC guidelines while violating them.
“Most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses,” Kertesz and colleagues wrote in response to the NCQA plan. “The proposed NCQA measure indulges no such subtleties.”
The discussion overall has been hindered by limited research, including evidence for the benefits of forced tapering. But as of October 2018, 33 states had codified some prescription limits into law. Pharmacies and insurers capped prescriptions at 90 MME. Law enforcement agencies warned high prescribers.
Some initiatives have focused on avoiding “new starts,” not on tapering legacy patients. But Kertesz and other advocates argued the pressure of all the policies and warnings inculcated an anxiety around prescribing.
Chronic pain patients were seen as legally risky and medically complicated, so they had trouble finding providers.
Kertesz and his allies raised their concerns in the popular and academic presses and at conferences, building momentum over the years. They collected anecdotes from patients who said they had been harmed in some way by dose reductions or involuntary tapers.
“It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” read a March letter co-authored by Kertesz calling on the CDC to reiterate its recommendations were not binding. The letter continued: “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
More than 300 patient advocates and experts, including three former White House drug czars, signed it.
About four years ago, Dr. Stefan Kertesz started hearing that patients who had been taking opioid painkillers for years were being taken off their medications. Sometimes it was an aggressive reduction they weren’t on board with, sometimes it was all at once. Clinicians told patients they no longer felt comfortable treating them.
Kertesz, a primary care physician who also specializes in addiction medicine, had not spent his career investigating long-term opioid use or chronic pain. But he grew concerned by the medical community’s efforts to regain control over prescribing patterns after years of lax distribution. Limiting prescriptions for new patients had clear benefits, he thought, but he wondered about the results of reductions among “legacy patients.” Their outcomes weren’t being tracked.
Now, Kertesz is a leading advocate against policies that call for aggressive reductions in long-term opioid prescriptions or have resulted in forced cutbacks. He argues that well-intentioned initiatives to avoid the mistakes of the past have introduced new problems. He’s warned that clinicians’ decisions are destabilizing patients’ lives and leaving them in pain — and in some cases could drive patients to obtain opioids illicitly or even take their lives.“I think I’m particularly provoked by situations where harm is done in the name of helping,” Kertesz said. “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”
It’s a case that Kertesz, 52, has tried to make with nuance and precision, bounded by an emphasis on the history of overprescribing and the benefits of tapering for patients for whom it works. But against a backdrop of tens of thousands of opioid overdose deaths each year and an ongoing reckoning about the roots of the opioid addiction crisis, it’s the dialectical equivalent of pinning the tail on a bucking bronco. Kertesz’s critics have questioned his motives. He’s heard he’s been called “the candyman.” (...)
Opioid prescribing has been declining since 2012, though levels remain higher than they were two decades ago. Today, depending on the estimate, anywhere from 8 million to 18 million Americans take opioids for chronic pain.
The interest in reducing their dosages is predicated in part on efforts to minimize patients’ risk of overdose and addiction. But there are other considerations. Enduring opioid use makes people more sensitive to pain, many experts believe. Opioid use has also been associated with anxiety, depression, and other health issues.
Plus, as people become dependent, the drugs might just be staving off symptoms of withdrawal that would come without another dose, rather than treating the original source of pain.
In short, experts say, long-term opioid use is not good medicine.
Kertesz, who is also a professor at the University of Alabama at Birmingham School of Medicine, agrees with all of that. But he believes that lowering dosages will hurt some patients who are leading functional lives on opioids, and that top-down strategies won’t protect them.
So, in 2015, when the Centers for Disease Control and Prevention proposed prescribing guidelines for primary care clinicians treating chronic pain, Kertesz grew nervous.
The guidelines, a set of measured recommendations finalized in March 2016, suggested clinicians try other therapies for pain before moving to opioids and prescribe only the lowest effective dose and duration of the drugs. (The guidelines do not apply to end-of-life or cancer care.) For patients on high doses, the guidelines said, “If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.”
“Our day-to-day practice aligns with nearly all principles laid out in the guideline,” Kertesz wrote in a comment he submitted on the draft. But he cautioned the voluntary recommendations could be implemented too stringently by others.
“This is a guideline like no other … its guidance will affect the immediate well-being of millions of Americans with chronic pain,” he wrote.
After the release of the guidelines, Kertesz started seeing ripple effects. In early 2017, federal officials unveiled a Medicare proposal that would have blocked prescriptions higher than 90 MME without a special review. Around the same time, the National Committee for Quality Assurance considered docking clinicians’ scores if they had patients on high doses for long periods.
Kertesz, other experts, and some medical societies protested such proposals, contending they invoked the CDC guidelines while violating them.
“Most of us wish to see an evolution toward fewer opioid starts and fewer patients at high doses,” Kertesz and colleagues wrote in response to the NCQA plan. “The proposed NCQA measure indulges no such subtleties.”
The discussion overall has been hindered by limited research, including evidence for the benefits of forced tapering. But as of October 2018, 33 states had codified some prescription limits into law. Pharmacies and insurers capped prescriptions at 90 MME. Law enforcement agencies warned high prescribers.
Some initiatives have focused on avoiding “new starts,” not on tapering legacy patients. But Kertesz and other advocates argued the pressure of all the policies and warnings inculcated an anxiety around prescribing.
Chronic pain patients were seen as legally risky and medically complicated, so they had trouble finding providers.
Kertesz and his allies raised their concerns in the popular and academic presses and at conferences, building momentum over the years. They collected anecdotes from patients who said they had been harmed in some way by dose reductions or involuntary tapers.
“It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” read a March letter co-authored by Kertesz calling on the CDC to reiterate its recommendations were not binding. The letter continued: “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
More than 300 patient advocates and experts, including three former White House drug czars, signed it.
by Andrew Joseph, STAT | Read more:
Image: Tamika Moore
[ed. Read the comments. America has a schizophrenic problem when it comes to mood-altering drugs (see here, here and here). Unfortunately, pain killers fall into this category. If the the ongoing 'War on Drugs' (and Prohibition before it) taught us anything, it's that targeting supply while ignoring demand is a recipe for failure (with sometimes horrific unintended consequences). People are dying not because drugs are easily available but because they aren't, and this uncontrolled environment creates an opportunity for all kinds of other Bad Things to happen (eg. flourishing crime organizations, dangerously adulterated products, property crimes, soaring suicide rates, etc.). The government and medical community's message: we want you to feel better, but not too good (and if unrelieved pain causes you to self-medicate, stick to approved drugs like alcohol, tobacco and anti-depressants; or just get more exercise, think positive thoughts and meditate your way out of the pain). One might reasonably ask why people need to escape reality in the first place (and if that's inherently a bad thing or just normal human behavior). Nearly every culture on earth since humans came onto the scene has had some form of mood-altering drug(s) as a component. See also: The Government's Cure for the Opioid Epidemic May Be Worse Than the Disease (Reason), and Faced with an outcry over limits on opioids, authors of CDC guidelines acknowledge they’ve been misapplied (STAT).]
