Let’s talk about the CDC and the DEA. Let’s talk about the newly minted 2022 CDC opioid prescribing guidelines and implementing those guidelines in the court of law.
Let’s start from the beginning. During the early 2010s, what most people characterize as the start of the opioid epidemic, we placed considerable emphasis on urine drug screens, and doses and quantities prescribed for opioids. In 2016, the CDC offered recommendations to help physicians navigate this increasingly complex, half-medical, half-legal world of opioids. They organized and codified newly minted guidelines through which providers were expected to manage patients. They standardized care, but shifted the provider’s perceptions away from direct communication, and toward the guidelines themselves.
As providers grew to rely on the guidelines to verify the need for opioids, they made decisions based on them.
If a urine drug screen came back positive for the prescribed opioids, then they would prescribe opioids. If negative, then they would abruptly stop. If a patient had a high dose of opioids, then they would be lowered to a recommended dose based on the guidelines. If the patient refused to lower her medications, then she would be dismissed by the provider.
Snap decisions based on the simplest interpretation of the guidelines limited all of patient care into an interpretation of the guidelines. But it was the safest decision for many providers, since it was the interpretation upheld in court. Sure, the CDC said back in 2016, and has continued to reiterate up to the present, including in the 2022 guidelines, that they are recommendations only – not hardened rules to adhere to. But the CDC isn’t implementing the guidelines in the court of law. That would be the DEA. And the rule of law has a funny way of setting the tone for the practice of clinical medicine.
George Washington said, “many ideas become false when taken to extremes”. The DEA’s simplistic interpretation of the CDC guidelines has led to an extreme approach to opioid prohibition. Countless physicians have faced criminal charges or DEA sanctions based on nothing more than an interpretation of a non-clinically trained DEA agent, who ascribes culpability by scrutinizing a provider’s clinical actions and decisions. Inevitably, this pits the provider against the CDC guidelines, with the DEA agent’s interpretation of the guideline holding the scales of moralized justice.
The opioid prescribing guidelines don’t address these differing perspectives. They won’t stop a drug-seeking addict from posing as a patient to secure prescription opioids, no matter how hard they try to scare providers. If the guidelines call for a restriction on the number of opioids prescribed, then an addict will simply visit the provider more often. If the guidelines call for urine drug screens, then an addict will find a way to pass the test. Restricting specific behavior in healthcare doesn’t stop the behavior, it simply makes that behavior harder to do – but it will get done, despite the increased risk.
We forget that. We think making something harder will stop it. It’s not true for other conditions like abortion or teen smoking, yet we doggedly insist on curtailing opioid prescribing through a maze of guidelines. Inevitably the guidelines fail in their intended purpose of reducing opioid abuse and overdose-related deaths. So we revise the guidelines. We add caveats. And then we revise them some more.
Instead of focusing on the guidelines, we should focus on the patient encounter. It’s where we find the perceptions that form between provider and patient. It’s in these critical moments that a patient with chronic pain receives a prescription for opioids.
It’s the heart of healthcare and is unlike any other setting found in society. Patients discuss the most vulnerable and intimate aspects of their lives, while providers analyze what they hear as they extract from their mental database of clinical knowledge. It’s a process that forms the patient narrative.
Though we never think of patient encounters as stories, our perceptions of healthcare are both conveyed and understood as narratives. This is what the guidelines miss. A single rule or a set of recommendations doesn’t capture the experience of implementing them in an encounter or having them implemented in your care. The real story of healthcare is the perceptions that form through that experience.
Marshall McLuhan’s famous quip, “the medium is the message”, conveys the notion that the context of a story – where and how it was said – is more important than the actual words spoken. Similarly, how the guidelines are implemented is far more important than the guidelines themselves, regardless of how many times we revise them.
This makes the DEA far more important than the CDC. The DEA is implementing the guidelines in the court of law, and their interpretation effectively defines the implementation of guidelines among providers and patients.
So when providers refer to the opioid guidelines when deciding whether to prescribe opioids, they aren’t parsing through the nuances underlying the context of the guidelines. They’re making the simplest, legally safest decision, using the guidelines merely to justify that course of action. This comes as the expense of good patient care. Look no further than the many chronic pain patients succumbing to suicide or suffering through intractable pain after their provider terminates their clinical relationship.
By reducing the complexity of medicine into simplified guidelines that serve as legal rubrics, the DEA has a framework to exact punitive measures against providers who veer away from their interpretations of what constitutes good care for chronic pain patients.
This is the elephant in the room, the thing that’s never mentioned when discussing the CDC guidelines. We applaud the revised guidelines for acknowledging uncertainty in patient care. We agree that individualized decisions must be made based on the unique needs of each patient.
That’s not the problem. The problem is that the DEA blatantly ignores this. That’s what’s missing in all the discussions about the revised guidelines.
It’s time we talk about it.