As 2018 comes to a close, I have reflected on legislation, polices, and a critical report that will likely continue to have an impact on the pain community in 2019. In no particular order, I have listed 5 issues that I feel were highly consequential for 2018.

1. CMS Decides to Impose Opioid Limits

Beginning on January 1, 2019, the Centers for Medicare and Medicaid Services (CMS) is introducing a limit on the amount of opioids — 7-day limits, and 90 MME caps — a provider can prescribe to a patient without requiring extra steps for approval. This limitation would be unrelated to the patient’s past experience or need.

Instead, the new CMS opioid prescribing policies are based on the CDC opioid prescribing guideline, which itself is based on weak evidence. Nonetheless, CMS and many states and insurance companies have adopted the guidelines as one-size-fits-all policies or limits.

The CMS policy is intended to help address the opioid crisis. However, at best, it will have limited impact because most people who are harmed by opioids are not likely recipients of Medicare or Medicaid. Moreover, Medicare and Medicaid patients are among the most disabled due to pain. Unfortunately, they may find it harder to find the pain relief they deserve in 2019.

2. CDC Opioid Guideline Forces Tapering

Forced downward titration has been broadly implemented throughout the country as a direct result of the CDC opioid guideline. Physicians feel pressured to follow the CDC recommendations of dose limits to avoid regulatory sanctions. In many instances, physicians have refused to treat people in pain with opioids. Sadly, some patents have even been abandoned by their doctors and have had difficulty finding any other doctor willing to treat their pain.

It appears that 2019 will not bring any dramatic changes in interpretation or application of the CDC guideline. It seems to me that there will have to be a cultural change in attitudes toward the needs of people in pain before there will be much improvement. Only social and political pressure will convince the CDC to update the guideline taking into account the unintended consequences the guideline has had.

3. Legislative Act, SUPPORT, Is Approved

Substance Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) was a major legislative Act in 2018. It had been in the making for several years and was finally approved.

Although the legislation failed to address many critical areas necessary to solve the pain and addiction problems in America, it was successful in providing funding for the discovery of new non-opioid therapies. This will not lead to new safer and effective medication in 2019, but it could provide a long-term solution that helps address the opioid crisis while meeting the needs of people in pain.

4. Human Rights Watch (HRW) Issues a Report About CDC Guidelines’ Potential Consequences

The nonprofit New York-based Human Rights Watch (HRW) issued a report, titled “Not Allowed to Be Compassionate,” that expresses concern about the CDC guidelines’ potential consequences for people in pain.

HRC is an organization that typically tracks and exposes war crimes. The organization believed that people in pain might fall into their jurisdiction, so they investigated the human rights concerns of people in pain. They published a report that describes the stigmatization of people in pain and their increasing challenges to receive humane treatment. It also accuses the U.S. government of demonstrating an indifference to the needs of people in pain while hyper-focusing on the opioid crisis.

The HRW’s recommendations for remedying the problem include:

• Implement the National Pain Strategy
• Limit the unintended consequences of prescription reductions for chronic pain patients
• Improve the availability, accessibility, and affordability of multimodal pain management, including to non-pharmacological modalities
• Improve data collection on involuntary tapering and the overdose crisis to allow the most effective response possible

To date, the HRW’s recommendations have not received the public attention that they deserve. The challenge for the pain community will be to spread the word about the report and make the HRW’s recommendations a topic of national discussion in 2019.

5. Farm Bill Legalizes Cultivation of Hemp

The passage of the 2018 Farm Bill is an unlikely place to find hope for people in pain, but that may be just what it has delivered. The Farm Bill removed hemp from an archaic classification of schedule 1 under the Controlled Substance Act. Until now, growing the hemp plant had been illegal in the United States. The passage of the 2018 Farm Bill means that farmers are now allowed to cultivate hemp on an industrial scale. As a result, it’s almost certain that more CBD products will be studied and become available for treatment of pain and anxiety.

It is always difficult to know what the new year will bring. Let’s hope that, by the end of 2019, we can report on 5 issues that have dramatically helped to make the lives of people in pain better while also curbing the opioid crisis. Both can happen, but it’s up to us. We must let compassion lead us forward but allow science to light the way. (phrase trademarked by Dr. Lynn R. Webster)

I wish everyone a healthy new year!