New Opioid Guidelines – What You Need To Know

//New Opioid Guidelines – What You Need To Know

New Opioid Guidelines – What You Need To Know

In March 2016, the Centers for Disease Control and Prevention (CDC) released new opioid guidelines. A draft of new opioid guidelines was previously introduced in October of 2015 sparking immediate concern and controversy. The finalized guidelines introduce new prescriber recommendations as well as strong language aimed at monitoring for over prescription and misuse of opioids. Many in the healthcare industry welcome these stronger opioid guidelines as a way to focus on different options for pain management, but some chronic pain patients worry that tighter controls will do more harm than good. It’s important to look at both sides of this controversial issue in order to see the benefits and potential pitfalls more clearly.

New opioid guidelines – A primer

The new opioid guidelines are aimed squarely at physicians who reach first for prescription painkillers when treating any kind of pain. While they are not law, these guidelines will serve as a foundational recommendation for best practices among physicians.

Highlights of the new opioid guidelines include:

  • Nonpharmacological interventions come first: Reaching for opiates as a first treatment option is strongly discouraged in these new opioid guidelines, especially for chronic pain.
  • Risk/benefit discussion: Physicians should have a discussion of the potential risks and benefits of opiates with new patients prior to starting opioid therapy. This includes a frank conversation about the risk of dependence or abuse.
  • Demonstrated improvement: In order to continue or justify opioid therapy, physicians must see improvement or demonstration of efficacy of the treatment.
  • Proper formulation: Immediate release opioids should be prescribed, rather than extended-release/long-acting (ER/LA) opiates.
  • Proper dosage: Dose should be the lowest possible to achieve desired result.
  • Short time frame: Patients with acute pain should only be prescribed opiates for three days or less.

The opioid guidelines that focus more on chronic pain call for a continual reassessment of the efficacy of opiates and include recommendations for:

  • Monitoring for prior abuse: Clinicians should carefully evaluate a chronic pain patient’s potential for abuse, including looking at family history and prior reported addiction or dependence.
  • Proper dosage: Dose should not increase without thoroughly revisiting the potential harms versus the benefits of therapy.
  • Frequent check-ups: Chronic pain patients on opioid therapy should be re-evaluated frequently. This may include annual urine testing for signs of improper use and monitoring the number and frequency of prescriptions.
  • Treatment for dependence: In case of dependence, physicians should be prepared to offer treatment options that may include introducing methadone.
  • Prescription interaction: Physicians should not prescribe opiates concurrent with benzodiazepines.

New opioid guidelines – The evidence

CDC director Thomas Frieden offers one compelling reason for these tighter recommendations:

“We know of no other medication routinely used for a nonfatal condition that kills patients so frequently. We hope to see fewer deaths from opiates. That’s the bottom line. These are really dangerous medications that carry the risk of addiction and death.”

In the U.S., an average of 40 people die per day due to prescription painkiller overdose, with another nearly two million either abusing prescription opiates or becoming dependent on them. As prescription rates for opiates rose sharply between 1999 and 2014, opiate dependence and death rates rose as well.

Dr. Debbie Dowell, senior medical officer at the CDC and the lead author on the new opioid guidelines, points out that as many as five percent of chronic pain patients are prescribed opiates. While this number may seem low, that translates into three million people in the U.S. taking daily opiates for chronic pain.

This is a definite shift from prescription rates prior to 1999 when opiates were predominantly utilized for acute pain and palliative care. Dowell points out that success rates for pain relief in the short term cannot necessarily be extrapolated to long-term chronic pain:

“…there are a number of studies that have shown some short term effectiveness, usually about a 20 percent to 30 percent reduction in pain…We have some indication that tells us we might not be able to apply the short term results of these studies to long term benefits. Opioids have unique characteristics, such as tolerance, that at least in some patients, mean physicians have to increase the dosages of these medications to get the same effects and that the effectiveness is less over time.”

Peggy Compton, professor and associate dean for research, evaluation and graduate programs and a pain and addiction specialist at Georgetown University School of Nursing and Health Studies, looks at the other side of the issue through the patient’s eyes:

“…one of my concerns with these guidelines is that we’re going to see more and more clinicians be more and more concerned about patients that ask for medications, concerned about patients misusing their medications when perhaps they aren’t. So, I do worry that the guidelines will — the pendulum will swing too far the other way and we’ll see clinicians who are uncomfortable prescribing medications.”

A caller to a radio program discussing the new opioid guidelines put it very plainly:

“My comment, really, is that when people need [opiates], they really, they really need [them].”

Chronic pain patients who utilize opiates are concerned that the new guidelines will make it difficult to get the relief that they need to function in their daily life. Even without significant clinical evidence to prove long-term efficacy of opiates for chronic pain, some patients feel opiates are the only treatment that works.

The new opioid guidelines clearly make exceptions for end-of-life care and cancer pain but also stress alternative pain management before reaching for the prescription pad.

Dependence on opiates is a growing problem that the CDC’s new opioid guidelines are trying to address. At the very least, they are opening up a powerful dialogue between doctors and their patients. Importantly, these guidelines are also helping people to see the powerful addictive quality of opiates, a quality that does not recognize the difference between a pain patient and a recreational user.

Dr. David Kolodny of Brandeis University and Physicians for Responsible Opioid Prescribing put it this way:

“…I think there’s this notion that there’s this subset of our population of this group of people that want to take drugs to get high off of them, and have a good time, and that group is accidentally killing themselves in the process of using these drugs irresponsibly. The idea that we’ve got these two distinct groups is just totally false. Opioids are highly addictive. Pain patients are getting addicted.”

Join the discussion – will the CDC’s new opioid guidelines affect you or someone you love? What are your thoughts on these new guidelines?

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By | 2016-11-17T15:36:08-07:00 April 14th, 2016|Tags: , , |3 Comments

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Pain Doctor
Pain Doctor was created with one mission in mind: help and educate people about their pain conditions, treatment options and find a doctor who can help end their pain issues.

3 Comments

  1. Avatar
    Allison May 11, 2016 at 1:26 pm - Reply

    I appreciate the CDC trying to cut down on opiate related deaths. That being said I’ve read all of the information I could find on the new guidelines that are trying to be put into place and the dangers and risks of opiates especially taken with Benzos. I’m a Chiari with fibromyalgia sufferer along with degenerative disc disease, spinal stenosis and bulging discs in my lower back. I have a syrinx at C-7 thru C-9 I think but probably more. I just remember it being quite elongated. I have a metal plate in the back of my skull from the Chiari surgery along with fusing 3 discs during the same surgery. Then I had three more discs in my neck two years later thru the front. They messed my muscles up so im having trouble swallowing. I’ve been on opiates for 20yrs staying with darvocet then moving to hydrocodone and was there for over 15 yrs, doctors during that 15th period tried to get me to move up from that to control my pain but I refused. Over the last two years I’ve had to give in because I couldn’t stand the pain anymore. Now I’m on oxycotin 40mg ER with the hydrocodone as a breakthrough med. I also am on valium and have been for a long time. I am at a point in my life to where I as m finally out of bed and . Am doing well. Before I’ve had to stop working due to my disease I was an MA and Xray Tech and my sister is an RN. We boo 18th have been in the medical field for many years and know the ramifications of the meds I am on but the benefits out way the concerns. Without them I have no life, I would just lay there and die, that’s no way to live. I’m sure I’m no out the only patient that has never had a reaction to meds before. I cannot tell when I take my meds other than having less pain. I’m sure allot of people say that but it’s true, I never have been able to even from the first pill I ever took. I’m a devout Christian and would never lie, I don’t know why I’m that way unless it’s the hypoglycemia. I’m also very careful when taking my meds and I do not drink alcohol. I take my blood pressure frequently and take very good care of myself. I’m willing to take the risk to have some quality of life. I feel so sorry for those who have lost their lives but I do not feel like I will be one of them. Thank you to the CDC for all their hard work in trying to keep us safe.

    • Pain Doctor
      Pain Doctor May 12, 2016 at 2:49 pm - Reply

      Hi Allison — It sounds like you’re working with a responsible doctor who is working to help you find relief from pain. We’re so glad to hear that.

  2. Avatar
    chris June 9, 2018 at 10:00 pm - Reply

    I am confused why I must suffer multiple dosage reductions while my medication has been the same for over 12 years. My quality of life has gone down and I may not be able to work after this newest round of federal regulatory mandates lowering doses. They’re setting maximum amounts for Medicaid and insurance companies will follow suit. This is an overreaction to an epidemic not related to me personally until the last few years….

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