Thread by @JillPiggott

2012 column by leading pain expert B Eliot Cole, MD, MPA, warned that "radical changes" proposed by a group calling itself #PROP would deny #opioids "to the majority of patients now receiving them for noncancer pain." / thread hcplive.com/view/just-how-…

In the early 2000s, "buoyed by the success of treating cancer-related pain with #opioids, many physicians rose to the challenge of doing more for their patients suffering with #ChronicPain," Cole wrote.

"This led to an increase in the number of prescriptions for #opioids, which had the unintended consequence of more opioids ending up in medicine cabinets in more homes, ultimately giving more people (🚩not patients) access to these valuable medications for nonmedical purposes."

In July 2012, #PROP asked the #FDA "to strike the term moderate from the indication for noncancer pain," add a max daily dose of 100 MME, & a max duration of 90 days for daily use of rx #opioids."

"I immediately had to ask 'Who died and left these people in charge?'"

Dr Cole, then a #pain practitioner w/ nearly 30 years of experience, reviewed #PROP's claims & concluded they "hadn't made their case."

Because there's "no precise measurement of pain, exactly how will the line between moderate and severe chronic noncancer pain be determined?"

"If #opioid analgesics are not anesthetics, why wouldn’t we expect patients to continue experiencing pain while taking opioids?"

If #ChronicPain is associated w/ depression about 1/2 the time, "why are we surprised that there are comorbid mental health issues?"

"If an individual patient has no problems associated with the use of 120, 180, or 240 mg of morphine equivalent on a daily basis, why do we need to reduce that dose?"

"If an individual patient is functioning well with #opioid therapy after 90 days, and there is no better treatment available, why would we stop treatment and inflict worsening pain?"

"Assuming we agree to restrict #opioids to fewer patients, will we really see fewer deaths, or just fewer deaths directly due to #overdose instead of #suicide?"

[JP: In fact, dose reductions are associated w/ a 3 to 6.8-fold rise in both ODs & suicides.]

"How exactly do we respect the patient’s right of autonomy & then override the decisions they make in consultation with their providers? What will become of the patient-physician relationship when absolute 'rules' are enacted, and no individual distinctions are permitted?"

Cole: "It has taken us more than 15 years to arrive at this current moment in time in the ongoing conversation about the role of #opioids in managing chronic noncancer pain, so we need to incrementally adjust prescribing behavior before we throw out everything we have done."

"Each one of us will have to set personal practice limits and rules," Cole wrote to his fellow doctors, "but please do not forget the need to treat #pain sufferers with compassion and be careful not to use a 'broad brush' approach to deny all patients access to pain relief."

🟠 Round 2 in What #PROP & Policymakers Got Wrong: 2016 paper, "Addressing the limitations of the CDC guideline for prescribing opioids for chronic noncancer pain."

Busse JW, Juurlink D, Guyatt GH. CMAJ. ncbi.nlm.nih.gov/pmc/articles/P…

"The limitations of the #CDC guideline include largely restricting involvement to experts who have been critical of #opioid use for chronic noncancer pain, limited involvement of patients, [and[ excessive restrictions on selection of evidence."

#CDC excluded more than 100 randomized controlled trials of treatment with #opioids & failed to adequately apply the Grading of Recommendations Assessment, Development and Evaluation (GRADE) rating system to address evidence quality.

#CDC made "excessive use of strong recommendations in the face of low-quality evidence."

In 2016, #pain experts warned that the harms of adopting the Guideline “could include withdrawal reactions, uncontrolled pain, anxiety for patients and loss of trust in their physicians.”

In 2019, the #FDA identified harms of sudden or rapid rx #opioid discontinuation, including "serious withdrawal symptoms, uncontrolled pain, psychological distress, and suicide."

fda.gov/drugs/drug-saf…

In 2016, in British Columbia, Canada, where the CDC Guideline was adopted as a standard of practice, found patients sought illicit #opioids to cope with uncontrolled #pain following taper. Given the “profusion of counterfeit #fentanyl,” the “consequences could be fatal.”

In 2019, the FDA warned doctors against rapid / sudden rx #opioid discontinuation because it leads some patients to seek illicit or illegal opioids like #heroin, "which may be confused w/ drug-seeking for abuse." The consequences are too often fatal.

These #pain experts, writing in 2012 and 2016, were right: denying people #opioid medicine has caused deaths, distress, & disability to RISE. The policy is making the terrible crisis of overdoses to illegal drugs WORSE.

Who will be the last to die for a mistake?

thread #cpp #spoonie #migraine @NitaGhei @headsUPmigraine
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