Photo Credit: Image: Triggermouse via Pixabay, Pixabay License.
Triggermouse
Not COVID. The other one.President Trump’s first week in office included an order suspending all CDC, HHS, and NIH communications: regulations, announcements, reports, advisories, updates, and online posts. This aligns with pruning federal bureaucracy. But silencing these three, of hundreds of agencies, is interesting.
COVID was, for many Americans, their first personal experience of vast, unregulated power imposed by federal agencies. Without enforcing laws or interpreting regulations, just publishing claims and data can have unrestrained power.
For many Americans, it was shocking and novel seeing suggestions rapidly morph into mandates, while mainstream and social media stripped contradictory evidence and contrary opinions from public discourse. Some citizens were inspired to push others to wear masks.
But COVID wasn’t the first time government actions that were neither laws nor regulations imposed dire consequences on ordinary, law-abiding Americans.
One agency muzzled by Trump, the CDC, exemplifies far-reaching federal influence. One example of the profound impact of CDC publications is the 2016 CDC guidelines for pain treatment with opioids. These guidelines — not regulations, not laws — initiated drastic, ongoing reductions in pain care nationwide.
The guidelines discussed pain patients who had never been prescribed opioids. The CDC recommended for these patients doses below 90MME per day. The guidelines didn’t discuss established patients with severe and chronic pain, or the wide genetic variability of sensitivity to pain and sensitivity to opioids. Although pain is often described as a subjective experience, it’s observable in animals and people unable to verbalize, including infants, coma patients, and dementia patients. Four of the top ten reasons for U.S. E.R. visits are pain (abdomen, chest, head, and general). Another, back problems, entails pain. Only for Spock, a fictional alien, is pain merely “a thing of the mind.”
Caution introducing new medication sounds reasonable. However, variability in pain and opioid sensitivity makes a one-size dosing, even for one subset of patients, or medical condition, unworkable. Chronic and severe pain often requires much more than 90 MME per day. Individual morphine tablets of 200mg are legally manufactured and prescribed.
Between 2011 and 2021, U.S. opioid prescriptions were down 40%. According to JAMA, from 2016 to 2018, prescriptions were down sharply. This trend began years before the guidelines.
After 2016, many insurers and medical groups, and state governments, drastically reduced prescribing these drugs, even for long established, successfully treated patients. The 90 MME limit is currently enshrined in laws in 40 states, often applying to all pain patients. Inpatient palliative care, especially for economically disadvantaged patients, has been significantly reduced.
In 2014, approximately 39.4 million Americans suffered chronic and severe pain. As of 2024, that number was over 60 million. In 2016, 1 in 10 U.S. veterans had chronic pain, and after the guidelines were published, veterans complained of insufficient pain treatment and rising veteran suicides.
Facing widespread criticism, CDC expressed surprise that the guidelines had been applied widely and swiftly. In a 2019 paper, the guidelines’ authors claimed that recommendations had been implemented incorrectly and pain patients were being deprived of necessary medications. Revised guidelines published in 2022 softened some recommendations, with no effect on post-2016 legislation.
The 2016 guidelines didn’t arise in a vacuum. Years of prior CDC publications featured flawed data. There was a detectable inference that legally manufactured opioids prescribed by professionals present a uniquely serious threat not only to patients, but to society.
To illustrate how prescription opioid deaths were supposedly underreported, a 2017 CDC report discussed Minnesota patients with pneumonia and opioid prescriptions who died between 2006 and 2015. The CDC argued that these should be counted as opioid deaths, not pneumonia deaths, as they had been.
A 2021 report in the medical journal Cureus examined a decade of CDC publications about opioid-linked deaths. From 2006 to 2016, CDC’s opioid prescription death totals were inflated by counting deaths linked to illicit fentanyl and methadone dispensed for substance abuse treatment. Methadone prescriptions for pain started declining prior to 2016. “What is clear from the authors’ inquiry is that, even today, the CDC has no way of determining the actual number of prescription opioid overdose deaths each year. For more than a decade, the CDC’s erroneous reports went unchallenged while being used by Congress and the Executive Branch as the basis for public policy.”
A 2021 Pain Therapy report shows that death attributed to opioids were over-reported by 20–30% — virtually the same percentage by which the CDC claimed opioid deaths were increasing. Almost 90% of deaths attributed to opioids included 1–4 other drugs on the death certificate, most frequently benzodiazepines. A 2021 CDC publication bluntly states that agency efforts to quantify overdose deaths are “falling short.” As of 2021, the CDC hadn’t complied with Congress’s mandate to improve its methods for tabulating OD deaths. Whereas one CDC publication reported that opioid deaths were up in 2020, another, in 2023, stated that they were up for the first time since 2018.
Considering the influence wrought by one publication on one subset of patients, data on that subset might be pertinent. A 2018 study in the BJM studied over two million opioid-naïve patients receiving surgery between 2008 and 2016. Their subsequent opioid misuse rate was 0.6%.
In 2016, JAMA published data for 641,941 subjects, with no opioid prescriptions for at least a year, receiving major surgery between 2001 and 2013. The reference sample of 18 million received no surgery. Depending on the surgery, rates of subsequent misuse ranged from 0.119% following C-sections, to 1.141% for total knee replacement. For the no-surgery control group, the rate was 0.136%.
Despite revised guidelines, and documented flaws in their opioid data, the CDC continues to publish flawed data. The influence of the 2016 guidelines continues to spread. We now have a return of opioid-free surgery, as well as the opioid-free emergency room.
Many medical professionals fear prescribing appropriate opioids from the misguided belief that opioid prescriptions are uniquely lethally dangerous, or fear facing legal battles like the plaintiffs in the Supreme Court Ruan case.
The influence the CDC exerted via publications alone cannot be undone with publications. At this point, CDC officials could appear in sackcloth and ashes, on social media blast, vigorously repenting of the 2016 guidelines, without affecting the sequela of their work in 2016.
For reasonable pain care, we’d need
- legislatures in 40 states to repeal post 2016 laws,
- professional medical education to cease depicting prescribed opioids as uniquely dangerous to patients and society, and
- the White House to stop financial rewards for Hollywood productions pushing narratives crafted by government drug warriors.
Even if all effects of the 2016 guidelines were entirely reversed, it will do nothing for patients who died by suicide following the sudden withdrawal or forced tapering of their prescriptions. That number has not been the subject of any federal research.
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Image: Triggermouse via Pixabay, Pixabay License.
