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Draft Of CDC's New Prescribing Guidelines Stirs Debate


The story of Americans and prescription pain remedies is a long one with a twisting, turning plot, and right now, we're in the midst of a turning point. Here's what a federal drug official told a New York Times interviewer. He said, of all the nations of the world, the United States consumes the most habit-forming drugs per capita. Some of our doctors, he told the Times, regard their liberty to prescribe as license to furnish to its victims the narcotic curse upon demand. You may have missed the interview with Dr. Hamilton Wright because it appeared back on March 12 of 1911. When Dr. Wright was named the country's first opium commissioner by President Theodore Roosevelt, morphine addiction in the U.S. was epidemic. Flash forward to this year, and president Barack Obama...


BARACK OBAMA: More Americans now die every year from drug overdoses than they do from motor vehicle crashes - more than they do from car accidents. The majority of those overdoses involve legal prescription drugs.

SIEGEL: Early next year, the Centers for Disease Control and Prevention is expected to publish new guidelines for prescribing opioids, drugs like OxyContin and Percocet. The guidelines are only advisory. They're not mandatory regulations, but doctors are sharply divided over how far the CDC should go to discourage opioid prescriptions. Dr. Richard Payne - that's P-A-Y-N-E - of Duke University is concerned that those guidelines may go too far.

RICHARD PAYNE: I see the country as being too much in the camp of, these drugs produce nothing but addiction.

SIEGEL: And the country has been there before. For most of the 20th century, doctors were loath to prescribe opiates. They risked punishment under the law if they did. Dr. Payne remembers the attitude toward these potentially addictive drugs when he was a medical student back in the 1970s.

PAYNE: I remember where even cancer patients were denied opioid medications because of concerns that they would become addicted. And you know, being addicted was viewed as being worse than dying in severe pain. And certainly when people did not have cancer, there was an even greater concern back in those days.

SIEGEL: By the mid-1990s, the pendulum was swinging back. Opioid use was back in favor and not just for cancer pain. There was a push to take pain more seriously, to consider it a vital sign, like body temperature or blood pressure. Doctors started asking patients to rate their pain on a one-to-10 scale.

At the same time, extended release formulations of opioids were developed and marketed very aggressively, sometimes dishonestly. The makers of OxyContin were prosecuted for claiming the drug was less-addictive than it is. The company paid fines of $600 million. Here's how Dr. Ajay Wasan, a pain specialist at the University of Pittsburgh, remembers those days.

AJAY WASAN: You know, these forces all come together, and then you have physicians and other providers believing that they can prescribe opioids for, you know, non-cancer pain, for chronic back pain, neck pain, knee arthritis pain, without any real negative consequences. People make leaps that they probably shouldn't make, and that's fueled in part by the pharmaceutical industry. I mean, the same forces that gave rise to the importance of pain also, you know - there's a dark side, and it can, you know, lead to some of the consequences that we have now.

SIEGEL: Those consequences, according to the CDC, include a quadrupling of opioid sales in the first decade of this century. Two-hundred-fifty-nine million opioid prescriptions were written in the year 2012, enough for every adult American to have a bottle of pills. Last year, nearly 19,000 people died from prescription opioid overdoses in the U.S.

JANE BALLANTYNE: I mean, the number of deaths is only the tip of the iceberg that's just indicating the pyramid of problems that lies beneath.

SIEGEL: Jane Ballantyne of the University of Washington is president of PROP, Physicians for Responsible Opioid Prescribing. The group advocates caution in prescribing the drugs which they say are often essential for easing suffering at the end of life and for short-term treatment of severe pain. But they're not the answer for every type of pain. For 20 years, Dr. Ballantyne directed the Center for Pain Medicine at Massachusetts General Hospital in Boston.

BALLANTYNE: It became really obvious to us that the patients who were being treated with very high doses of opiates were absolutely miserable, were not doing well, were medically ill and always had severe pain despite being on high doses of opiates. And we began to wonder if, the very least, the opiate wasn't helping, and maybe it was harming.

SIEGEL: Dr. Ballantyne advised the CDC on their new guidelines, which are now open for public comment. They're mainly aimed at treating chronic pain. They're not meant for cancer patients or other end-of-life care. Among their proposals, prescribe opioids only after considering other drugs and other treatments that don't involve drugs. If you do prescribe opioids, discuss the risks and likely benefits with the patient and start with low doses and shorter durations. Dr. Jane Ballantyne says action from the top down is necessary to counter the reactions that doctors get from patients when they prescribe these powerful drugs.

BALLANTYNE: If you give people opiates, they think you're the best thing since sliced bread. They love you. They just worship the ground you walk on. The moment you suggest that you want to try and get them down on their dose or, worse still, say you can't carry on prescribing - not that I do that myself; I never cut people off; I don't think people should be cut off, but I do try and persuade them to come down on their dose - they are so awful. And you can see why people who are not seeped in this stuff - the young primary care physicians just don't know what to make of it. They don't want to be abused. They want to be loved like everybody else does. We go into medicine to try and help people. And when you get abused and, you know, insulted, you can see why it perpetuates itself.

SIEGEL: Dr. Ballantyne says the widespread use of opiates is fueling an addiction epidemic. Dr. Richard Payne disagrees. He says correlation does not equal causation, and he says don't think of people who take opioids as drug abusers.

PAYNE: There are populations of people who have chronic pain caused by conditions that are not terminal who use medications appropriately, don't divert them, don't overdose on them and actually improve their function and are able to live better. We have a moral responsibility to address pain and suffering. And we do have a responsibility not to do harm, but you can do harm in either direction.

SIEGEL: Dr. Richard Payne of Duke and the other doctors we heard earlier are pain specialists. The forthcoming CDC guidelines are directed at primary care doctors. They write nearly half the opioid prescription. We'll hear from one of them, Dr. Wanda Filer, the president of the American Academy of Family Physicians, tomorrow.

WANDA FILER: It makes you squirm a little bit more - not so much the science of opioid prescribing but that dance of, how much do I accept what this patient is telling me at face value versus how much do I have to be a healthy skeptic for their safety but also for the health of the public?

SIEGEL: Join us tomorrow when we continue with our coverage of opioids and the challenges facing the family doctor. Transcript provided by NPR, Copyright NPR.

Prior to his retirement, Robert Siegel was the senior host of NPR's award-winning evening newsmagazine All Things Considered. With 40 years of experience working in radio news, Siegel hosted the country's most-listened-to, afternoon-drive-time news radio program and reported on stories and happenings all over the globe, and reported from a variety of locations across Europe, the Middle East, North Africa, and Asia. He signed off in his final broadcast of All Things Considered on January 5, 2018.