CDC Gives Primary Care Doctors Guideline on Prescribing Opioids

Responding to an epidemic of opioid and heroin abuse, the CDC today issued a new guideline for doctors prescribing opioids for chronic pain. This guideline is targeted at primary care physicians and not those treating cancer patients, or those in palliative or end-of-life care.

The guideline offers recommendations on using opioids in patients whose pain persists longer than 3 months, or beyond the time of normal healing. Primary care physicians account for nearly half of all opioid prescriptions and typically treat adults in outpatient settings. While this use of opioids can be effective, use of these drugs can pose risks.

The sheer volume of prescriptions illustrates the problem, CDC reports. “In 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills,” write guideline authors Deborah Dowell, MD, Tamara M. Haegerich, PhD, and Roger Chou, MD. “Opioid prescriptions per capita increased 7.3% from 2007 to 2012, with opioid prescribing rates increasing more for family practice, general practice and internal medicine compared with other specialties.

“Rates of opioid prescribing vary greatly across states in ways that cannot be explained by the underlying health status of the population, highlighting the lack of consensus among clinicians on how to use opioid pain medication,” the authors note.

Among the 12 specific recommendations in the guideline, there are 3 broad principles:

· Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, or end-of-life care.

· When opioids are used, the lowest effective dose should be prescribed to reduce risk of opioid use disorder or overdose.

· Providers must exercise caution and closely monitor patients when prescribing opioids.

Broader availability of oxycodone—sold under the name Oxycontin—starting in the mid-1990s is widely blamed for the rise of opioid abuse. When patients lose access to this drug, some who have become dependent on it switch to the chemically related drug heroin, and results can be deadly.

CDC reported in July 2015 that deaths from heroin had quadrupled in the past decade. In December the agency reported that in 2014, more people had died from drug overdoses than any year on record. No demographic or part of the country is untouched by the epidemic, which has become an issue in the presidential campaign—in both parties. A survey the Kaiser Family Foundation found that 56% of all Americans had a direct connection with someone who had struggled with opioid or heroin addiction or had died of an overdose. Just last week, HHS announced $94 million in grants to federal heatlh centers to screen patients and direct them to treatment for opioid and heroin addiction.

"More than 40 Americans die each day from prescription opioid overdoses; we must act now," said Tom Frieden, MD, MPH, director of CDC. "Overprescribing opioids--largely for chronic pain--is a key driver of America's drug-overdose epidemic. This guideline will give physicians and patients the information they need to make more informed decisions about treatment."

The agency produced a checklist for physicians as well as guides for talking with patients’ use of therapy, including understanding the benefits and harms of opioids if they are used.

“Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks,” the guideline states.

“Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.”

Specifically, the CDC guideline notes that long-term dependence often begins with treatment for an acute pain, typically an injury. Thus, the guideline calls for prescribing the immediate release form of the drug instead of an extended release form. “Three days or less will often be sufficient; more than 7 days will rarely be needed.”

Reference

Dowell D, Haegrerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States 2016. MMWR recommend rep. ePub: March 15, 2016. http://dx.doi.org/10.15585/mmwr.rr6501e1e