They are changing the rules of the game


Will CDC Guidelines Promote Addiction Treatment?

People who take opiates … NO LONGER DEPENDENT OR AN ADDICT …but.. you now have a “OPIATE USE DISORDER “

By Alison Knopf, Editor of Alcoholism & Drug Abuse Weekly

The quick answer to the question “Will treatment providers be able to treat patients coming in addicted to opioids because they have been thrown off their pain medications next year?” is no. The treatment system can’t even treat all the patients who need help now. But this question is on the minds of federal policymakers as the federal Centers for Disease Control and Prevention (CDC) works on its forthcoming guidelines for physicians on prescribing opioids, due out next January (see ADAW, Nov. 16).

While the pain community is creating the loudest noise about the forthcoming guidelines, charging that they are not addicts and don’t want to be lumped in with them, the treatment community has on the one hand seen the benefits of decreasing the amount of prescription opioids available, but also seen the downside: patients who are dependent or addicted, who cannot successfully taper off the pain medications, will switch to heroin. Many started as legitimate pain patients.

But for some, when their doctors felt they no longer needed the pain medication, or thought the patient was doctor-shopping, or simply decided to go along with the calls to reduce the amount of prescriptions for opioids, it was difficult to stop, and they sought illicit sources of opioids.

The CDC confirmed to ADAW that there will be a guideline that “addresses treatment for opioid use disorder.” The draft guidelines leaked in September specifically recommended that an opioid agonist (methadone or buprenorphine) be arranged for patients who need treatment for an opioid use disorder. The CDC said the guidelines are continuing to be revised. Below is the wording of that recommendation from the September draft:

“Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.

SAMHSA Working With CDC

But how the primary care physician determines whether a patient has an opioid use disorder is unclear. The Substance Abuse and Mental Health Services Administration (SAMHSA) expects there to be a change in prescribing practices — that’s the whole point of the guidelines. But according to Robert Lubran, director of the Division of Pharmacologic Therapies at SAMHSA’s Center for Substance Abuse Treatment (CSAT), it’s up to the physicians who are prescribing the medications to come up with a referral plan for their patients.

“I go back to what Westley Clark always said,” Lubran told ADAW, referring to the former director of CSAT. “He said the physician has to have an exit strategy for a patient he isn’t going to be prescribing opioids for anymore.” The physician has to determine if the patient is dependent on or addicted to the medication. Dependence is a normal result of regular opioid intake, addiction is pathological, but both will result in withdrawal symptoms when opioids are stopped suddenly. Someone who is dependent can be slowly tapered off the opioids and endure the craving that ensues. Someone who is addicted cannot stop and will seek opioids from another source.

“There has to be a place where the doctor can refer someone when the doctor determines that the patient can’t be safely tapered down because they are addicted,” said Lubran. A treatment provider specializing in opioid use disorders, such as an opioid treatment program (OTP) or office-based opioid treatment (OBOT), would be a good solution, he said. “We’re working with the CDC to make sure the guidelines include information on where to refer these patients,” Lubran told ADAW.

“We’re already struggling on the traditional medicine side with how a patient goes from being a pain patient to being an addict,” said Lubran. “They discharge them, but what about referrals? More states and counties need to be involved in recommendations for care,” said Lu, adding that insurance companies need to be involved as well.

Guidelines Not Mandatory

Mark Parrino, president of the American Association for the Treatment of Opioid Dependence (AA-TOD), said that as far as he knows, OTPs have not been involved in the development of the CDC guidelines. However, he expressed skepticism about the effect of the guidelines. “Will there be a reaction by physicians? Will this really change their practice patterns? Will there necessarily be a wholesale dumping of patients who are getting pain medications? I would hope not. But if that is the result, I would ask how we are going to know whether these patients will show up in treatment, or go into the street for drugs?”

Furthermore, said Parrino, these are just guidelines from the CDC. “Doctors aren’t even required to read the stuff,” he said. “They’ll issue a big press statement, yes. But it’s like package inserts. Do you really think every physician will be watching their computer for the guide-lines, saying ‘Now I need to change my medical practice?’”

The CDC itself says as much. “It is important to note that, like other CDC guidelines, including prevention and treatment of sexually treated diseases, the guidelines are intended to support informed clinical decision-making but are not mandatory (that is, physicians are not required to follow these guidelines),” according to Courtney Lenard of the CDC’s press office. The CDC’s guide-line is meant to “help primary care doctors provide safer, more effective care for patients with chronic pain” and at the same time “help reduce use, abuse and overdose from these powerful drugs,” the CDC’s press office told us last week. “The guideline is intended for primary care providers who treat adult patients (age 18 and older) for chronic pain in outpatient settings, and is not intended for patients who are in active cancer treatment, palliative care or end-of-life care.”

Asked if restrictions on prescription opioids will lead to increased use of heroin, however, the CDC continued to stick to the federal official answer, which is: No. “There is no robust evidence that recently enacted policies regarding prescription opioids are responsible for large-scale shifts to heroin,” said Lenard, adding that only 1 in 25 people who use prescription opioids nonmedically start using heroin within five years. However, she added that this “translates into a major and growing epidemic of heroin use given how widespread the misuse of prescription opioids has become.” Stopping the misuse of prescription opioids is the best way to stop the heroin epidemic, according to the CDC.

This article is republished with permission of Alcoholism & Drug Abuse Weekly, which provides news and analysis of federal and state public policy developments, private sector business developments, and provider issues and innovations in addiction treatment.

7 Responses

  1. And I forgot to mention that one of the doctors I saw to make sure that my pump was still functional after 2 years of being empty and I requested a copy of my medical records from this doctor and she wrote down that substance abuse disorder was my primary diagnosis and complex regional pain syndrome was my secondary diagnosis. What can we do about such a slanderous comment being made in our medical records?

  2. Come on now. How vast is the intellectual dishonesty in this case? If you have a Wendy’s and McDonalds that are close in proximity to one another and Wendys see a subsequent spike in sales after the McDonald’s closed down? Wouldn’t that be evidence that the McDonald’s closure had a direct relationship on increased sales at Wendy’s? Common sense sure is a rare commodity these days.

  3. “There is no robust evidence that recently enacted policies regarding prescription opioids are responsible for large-scale shifts to heroin,…” The genesis for this statement is rooted either in naïveté and ignorance or in outright deception. These so-called “Policy makers” assume that we are both stupid and unobservant or simply nod yes with a glassy eyed smile as we believe everything that is issued from the State’s own “Ministry of Truth”. A few decades ago when I was a relatively uneducated pharmacy school student and had just learned the laws governing the “everything” legal and illegal of Controlled Substances, I quickly noticed the CSA of 1970-driven game called “Whack-a-Mole” that the DEA and everyone else involved in the “illicit” opiate trade were playing.

    The only thing that has changed is that some chronic pain patients are resorting to the use of heroin too as their legitimate medication supply chain has been denied them. These folks are caught in between two ruthless adversaries trying to out gun and out maneuver each other. They are not addicts in the proper and clinical sense of the term. The only thing that they are addicted to is not being in pain. The cadre of the holders of the State’s Punitive Priesthood is too ignorant and too brainwashed to be able to discern the difference between these otherwise law abiding individuals and the addicts that will sell their children to human trafficker’s for a fix. The chronic pain patients end up labeled as addicts when the truth is that if a label must be affixed, they would be more correctly labeled with Psuedoaddiction. Outwardly, their behavior may appear the same, but inwardly, they are trying to ameliorate an intense and a very real syndrome of chronic pain. There is nothing illegal or pathological about their desire to try and live both a reasonably productive and decent quality life.

    So for a given mouthpiece of the State, who truly should know better, to say that “There is no robust evidence that recently enacted policies regarding prescription opioids are responsible for large-scale shifts to heroin,…” is yet another of the almost endless examples of dissembling, obfuscation and other sundry prevarications that the State is spewing to avoid taking any responsibility for the havoc that their 45 year old, officially declared, War on Drugs continues to inflict on the genuine innocents that are being ground to powder as collateral damage. It’s really just a variation of the WWII era euro-fascist propaganda promotion practice of, “Tell a lie, make it a big one and tell it often enough and soon enough, the masses will believe the lie over any competing truth.” My mother told me, as a child, that liars go to Hell when they die. I’m sure there is a special room built just for these perfunctory Statist bureaucrats, complete with a wall thermostat that is permanently stuck on ∞.

  4. Oh my God.

  5. “Stopping the misuse of prescription opioids is the best way to stop the heroine epidemic”


    • It’s like their stupid thinking with gun control….they will never get that the bad guys will still get firearms no matter what the laws are while legal owners/purchasers can’t have them and are left defenseless. Look at the recent terrorist attacks in Europe. Oh yeah Prohibition worked so well with alcohol here in the US in the 20s and 30s….NOT!!!!

  6. This ongoing subject matter, which was strategized and planned prior to the health care reform address along with fear-provoking psychological notices put on public library boards aimed only for the elderly and disabled has evolved into a disease itself, and is creating and exacerbating serious mental-illness, decreased health and heightened suicide rates. This is Terror psychology. I believe this is really about immobilization, depopulation and world control through shock and awe, PTSD manufacturing as these covert military strategies have proven to be effective throughout the history of war; only this one is of high-technology. This is the worse pain as it affects mind, body and soul; and with the IEEE merging with radio, we feel even more isolated because the propaganda is so thick and denial is so deep, it’s only natural to run for cover, safety, or anything to take away pain of this magnitude.

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