The original guidelines were intended mainly for primary care providers, and the idea behind the recommendations was to stop communities from being flooded with painkillers. However, the guidance has been misapplied as a mandate, and all types of doctors, including pain specialists, have reduced or eliminated prescriptions.
By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.
But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”
If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers.
Even people the C.D.C. exempted from the guidelines seem to have been hurt. A 2022 study found that opioid use among patients with cancer fell between 2013 and 2018, with the steepest decline occurring after the guidelines were introduced.
“We normally don’t mandate or incentivize actions in health care where lots of papers say it could do harm and a few say it might be helpful,” said Stefan Kertesz, a professor of medicine and public health at the University of Alabama at Birmingham. “And we certainly wouldn’t mandate that those actions be done on a patient who has not consented.”
To ensure that people in pain stop becoming collateral damage in the drug war, the C.D.C. and other policymakers must change course. The revisions posted for comment make some critical concessions. Importantly, they eliminate the 90 M.M.E. per day recommended dosage cap. This is crucial not only because some people need much higher dosages but also because the method of calculating it is imprecise.