The 2016 CDC opioid guidelines were followed. Within 24 months, fatal overdoses had doubled. Charles LeBaron, MD, spent his career at the CDC. He is an internal medicine and pediatric physician, and he learned the second half of this story from an ICU bed. A staphylococcal septicemia put him in the hospital, then meningitis, then collapsed vertebrae in his neck and lower spine, and then disseminated shingles ulcerating half his body while he was still fighting the first infection. He came out of it with an intimate understanding of severe pain and of the obstacles standing between a person in severe pain and relief, some of which his old employer had helped construct. The sequence is worth walking through, because it reads as a policy failure and not as a villain story. In the 1990s, the consensus was that pain was undertreated. Opioid manufacturers read that consensus as a profit environment and promoted accordingly. The result was a prescription overdose crisis. The CDC responded in 2016 with three restrictions: narrow who gets opioids, cap the dose, cap the duration. Every one of them had evidence behind it. People on high doses for long periods really are more likely to end up addicted. What the guidelines did not account for was the population that already existed. Addiction treatment was not widespread. Alternatives to opioids were not freely available. So a large group of opioid dependent people lost legal access more or less at once. Entrepreneurs in Sinaloa had been selling heroin to a fixed customer base. Now there was a much larger one. They moved fentanyl into it, and cartels do not hold to the safety procedures or the dosing an FDA opioid would. Overdose deaths exploded. The result is the paradox LeBaron describes: severe restriction on prescription opioids for people who need them, alongside wide availability of far more dangerous illicit ones. The worst of both. LeBaron quotes Churchill on this. However beautiful the strategy, you should occasionally consult the result. Within 24 months the fatal overdose count had doubled. It took roughly five years for the CDC to revise. And the 2022 revision has a second problem. Insurers, pharmacy benefit managers, Medicaid and Medicare had embedded the 2016 numbers in their own rules by then. Loosening the federal guidance did not loosen the implementation. LeBaron's assessment: it's a piece of paper. Two practical notes from the episode for anyone still prescribing in this environment. The DEA no longer treats exceeding the guidelines as inherently criminal, though physicians have gone to jail over this, and the caution is rational. Naloxone is available over the counter as a nasal spray. Write it as a prescription anyway. Patients get no insurance reimbursement on the counter version, and most plans will cover the prescription. It is a strange recommendation and it is the one that keeps the antidote in the house. Overdose is now the number one killer of adults between 18 and 45, above guns and automobile accidents combined, above every single cancer. Listen to the full conversation on The Podcast by KevinMD. Link in the replies. What is the change to prescribing rules you would make first if the constraint were evidence rather than liability? #ThePodcastbyKevinMD