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.
- 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?