Pubdate: Sun, 20 Mar 2016
Source: Chicago Tribune (IL)
Copyright: 2016 Chicago Tribune Company
Contact:  http://www.chicagotribune.com/
Details: http://www.mapinc.org/media/82
Author: Steve Chapman

FEWER OPIATES MEAN MORE SUFFERING

There is no problem so bad that government-imposed remedies cannot 
make it worse, spawn new problems or both. A new confirmation of that 
phenomenon may be on the way, thanks to new recommendations from an 
agency intent on curbing the use of opiates.

On Tuesday, the Centers for Disease Control and Prevention issued 
guidelines for medical professionals to discourage them from 
prescribing these medicines to relieve pain. The agency has grounds 
for concern: Drug overdoses are now the leading cause of accidental 
death in the United States, with prescription and nonprescription 
opiates accounting for the biggest share of those fatalities.

Things apparently are getting worse. Since 2001, the number of deaths 
from overdoses involving legal prescription opiates has more than 
tripled, while the rate for heroin, an illicit drug, has risen sixfold.

These trends are the byproducts of a worthwhile change: more 
aggressive efforts by doctors to prevent suffering. In the 1990s, 
experts realized that patients suffering from both acute and chronic 
pain were being deprived of remedies. They also concluded that the 
danger of those patients becoming addicted had been exaggerated. The 
word went out, and over the past two decades, prescriptions for 
opioid painkillers have more than doubled.

The increase has been a blessing to millions of people whose ailing 
bodies had become cauldrons of misery. But alarmists think the side 
effects outweigh the benefits. So the CDC advises physicians to limit 
such prescriptions for short-term pain (say, from surgery) to three 
days or less.

As for chronic, persistent pain, the agency recommends that patients 
first be treated with ordinary painkillers (such as ibuprofen or 
acetaminophen), physical therapy or antidepressants. If opiates are 
eventually used, doctors are told to monitor patients to make sure 
the drugs are actually doing the job.

It all sounds reasonable, but the guidelines pose real risks. They 
will undoubtedly dissuade some medical professionals from offering 
medicines that can be extremely helpful. By giving priority to the 
danger of overprescribing, the CDC will create errors on the side of 
underprescribing.

But it's better to give some patients medicines they don't need than 
deny other patients medicines that they do. The CDC advice would tilt 
medical practice in the opposite direction. A broad effort to 
diminish the medical use of opioids will increase the net total of suffering.

There is more than enough already. "Pain affects millions of 
Americans; contributes greatly to national rates of morbidity, 
mortality, and disability; and is rising in prevalence," said a 2011 
report commissioned by the federal Institute of Medicine. "Currently, 
large numbers of Americans receive inadequate pain prevention, 
assessment, and treatment."

The American Academy of Pain Medicine, which represents pain 
specialists, was distinctly lukewarm on the CDC advice. It stressed 
that opioids "are an important option - as part of a comprehensive 
multidisciplinary approach - that must remain available to physicians 
and appropriately selected patients." It also noted the need "to 
ensure that it does not inadvertently encourage under-treatment, 
marginalization, and stigmatization of the many patients with chronic 
pain that are using opioids appropriately."

The new guidelines, billed as voluntary, feature a club in the 
closet. Medical professionals whose judgment contradicts the CDC's 
may find themselves under scrutiny from regulators, insurance 
companies and the Drug Enforcement Administration. "Just the 
knowledge that you are being watched casts a chilling effect," 
Jeffrey Singer, a general surgeon in Phoenix, told me.

States that impose prescription monitoring programs do see a decline 
in opioid prescriptions. But a working paper by Angela Kilby, a Ph.D. 
candidate in economics at MIT, documents that they lead to more 
unrelieved pain, higher costs, more missed workdays and a temporary 
jump in overdose deaths from heroin.

One possible explanation for this last result is that when pain 
victims lose their legal opiates, some resort to the illicit version 
- - which can be especially hazardous because they vary so much in 
potency and purity. Without a doctor's supervision, these patients 
may be more prone to mix opiates with other drugs. Most overdose 
fatalities stem from combining heroin with alcohol, cocaine or 
prescription medicines.

An old maxim says, "We all have strength enough to bear the suffering 
of others." There is no doubt that when prescription painkillers are 
widely available through physicians, some people will fake symptoms 
to get drugs to misuse or sell. But punishing the innocent to get the 
guilty is a formula for increasing the sum of suffering.
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MAP posted-by: Jay Bergstrom