The leading public health agency in the United States is urging doctors to stop prescribing opioids for patients suffering from chronic pain, noting that the risks of taking such drugs far outweigh the benefits.
The Centers for Disease Control and Prevention (CDC) recently published updated guidelines for distributing these powerful, highly addictive drugs. Vicodin and OxyContin are two prescriptions included in the guidelines. These measures come as a result of the nation’s prescription painkiller epidemic, which the CDC says poses a compelling threat to the health of the country.
The new guidelines do, however, provide exceptions for patients receiving cancer therapy or other forms of end-of-life care. When physicians deem these drugs necessary in other situations, the CDC recommends they be in the lowest possible dose for the shortest period of time.
CDC Director Thomas Frieden said in a statement that public health officials know of no other medications used for nonfatal conditions that contribute to more deaths. The guidelines’ aims, according to Frieden, are to decrease the rate of preventable deaths from opioids and to solidify the drugs’ status as dangerous medications that should be used sparingly.
Why The CDC?
The Centers for Disease Control and Prevention is the largest health agency in the United States. As one of the largest operating arms of the Department of Health and Human Services, the CDC works to protect America from health and safety threats, both foreign and domestic. Its principal aim is to protect health security in the United States: whether those threats come from human error, are chronic or acute, preventable or curable. In this case, opioid addiction is preventable, and the CDC is working to address the growing number of deaths and injuries related to opioid use that increase with each passing year.
As part of its duties, the CDC compiles a report of causes of morbidity (conditions that decrease quality of life) and mortality (death). Its job is then to address the biggest problems that cause disability and death for Americans. Opioid addition is already at epidemic proportions in the U.S., so much so that the CDC has intervened in an effort to slow the tide of preventable deaths stemming from opioid overdose.
The State Of Opioid Addiction In The U.S.
According to a report released by the CDC, more people died of drug-related overdoses in 2014 than any other year ever recorded. More than 60% of these deaths involved an opioid or opiate (a naturally occurring form of the drug). Since 1999, deaths from overdoses involving an opiate have quadrupled.
Between 2000 and 2014, roughly 500,000 people died from overall drug overdoses, while an average of 78 Americans die each day as a result of an opioid or opiate overdose. Of these, about 40 involve prescription opioids. In 2013, nearly 2 million people abused or admitted to being dependent on prescription opioids.
The CDC has identified these legally written prescriptions as a driving factor in this marked increase in mortality. The number of prescription-only opioids sold in the United States has quadrupled, as have deaths from drugs like oxycodone, hydrocodone and methadone.
Yet, there has been no change in the amount of pain that Americans report. Officials at the CDC have traced these numbers back to physicians’ behavior of writing prescriptions. The CDC maintains that controlling the number of opioid prescriptions can drastically reduce the amount of abuse of the medictations.
The Unfortunate Connection Between Opioids And Heroin
One of the main problems with opioid use is its link to illegal and dangerous drugs. Since prescription opioids are highly addictive, users will often turn to similar drugs, such as heroin, when their supply runs out. Indeed, there are an estimated 467,000 Americans currently addicted to heroin, according to the National Institute of Drug Abuse, a department of the National Institutes for Health (NIH).
The NIH also reports that the number of prescriptions written for painkillers has skyrocketed in the past two decades, from an estimated 76 million in 1991 to more than 207 million in 2013. The United States is the leading consumer of these drugs by a large margin, accounting for nearly 100 percent of the market for hydrocodone (Vicodin, Norco, etc.) and 80 percent of oxycodone (Percocet, OxyContin, etc.) sales.
Why Are Opioids So Addictive?
Prescription opioids affect the same brain systems as heroin and morphine do, meaning they are highly addictive drugs. When these drugs are crushed, snorted or injected, it increases their euphoric effect, but these methods also increase the likelihood of overdose.
Opioids work by attaching to proteins on nerve cells, which reduce the perception of pain. We all produce endogenous opioids naturally in our bodies; endorphins are an oft-cited example. Repeated use of synthetic opioids inhibits the production of endogenous opioids, which creates symptoms associated with withdrawal when one ceases use of prescription opioids. In order to stave off feelings of withdrawal, prescription drug abusers will often turn to similar drugs, such as heroin.
The number of past-year heroin abusers has risen steadily. In 2005, there were an estimated 380,000 heroin abusers, which jumped to 670,000 in 2012. Heroin poses a unique threat because there’s no way to guarantee the drug’s purity. Once exclusively an urban problem, heroin is affecting large and small communities alike.
Transition to intravenous drugs like heroin also leads to an increased risk for HIV and hepatitis C. In an effort to curb the heroin and opioid epidemics, the CDC’s new recommendations address opioids that are prescribed for chronic pain, intended to help those who are most vulnerable to becoming addicted.
What Are The New Recommendations On Opioid Prescriptions?
The CDC Guidelines for Prescribing Opioids for Chronic Pain are primarily directed to primary care physicians (PCPs) who prescribe almost half of all opiates. These guidelines provide recommendations for prescribing opioids for patients aged 18 or older. The document focuses on the use of opioids to address chronic pain, which is defined as pain lasting longer than three months or past the time of normal tissue healing. The guidelines also provide exceptions for palliative care and active cancer treatments.
According to the document, about 20 percent of patients with non-cancer pain symptoms receive an opioid prescription from their primary care physician. Given the time constraints of PCPs, prevention and appropriate treatment of chronic pain pose challenges.
The CDC now recommends that primary care providers take the following steps to minimize patient exposure to opioid drugs:
- Use alternative therapies. Nonpharmacological intervention, such as cognitive therapy and exercise, can be used as initial treatments for chronic pain. Doctors may also recommend non-opioid therapies like nonsteroidal antiinflammatory drugs.
- When opioids are warranted, prescribe the lowest dose for the shortest amount of time. Start with immediate-release versions. Don’t turn to prolonged-release versions unless absolutely necessary.
- Follow up with the patient routinely to assess their reaction to current therapy. If the benefits do not outweigh the risks, discontinue the therapy. Optimize your treatment plans to facilitate the winding down of opioid use when indicated.
How Are These Guidelines Different Than Before?
The new CDC guidelines place a lower threshold for exercising caution in prescribing opioids. Higher doses of opioids exponentially increase the risks of overdose and death. These guidelines establish that even relatively low doses – 20 to 50 MME (morphine milligram equivalents) – can increase risk.
Older guidelines also focused most of their safety precautions on so-called high-risk patients, but now the CDC recognizes that opioids pose a threat to all patients. Current screening tools and questionnaires cannot accurately rule out risk of abuse. Therefore, the new guidelines focus not only on reducing the risk across all patient populations, but they also encourage PCPs to use new technologies like state-funded drug-monitoring programs instead.
When the risks outweigh the benefits, the new guidelines also provide more-specific instructions for tapering and discontinuing opioid use.
When Might A PCP Prescribe An Opioid For Chronic Pain?
The CDC’s new guidelines are just that: They’re not actual rules. Physicians are not required to follow them, but the CDC hopes that these guidelines will begin to change prescribing behavior across the country.
Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, applauds the initiative. He called the move the first real attempt by the federal government to communicate that treating common ailments with hard drugs like opioids is inappropriate, even dangerous. Current prescribing behavior, he noted, was contributing to a public health crisis.
CDC Director Tom Frieden maintains that opioids should to be prescribed for an average of only three days, particularly in instances of acute pain. Taking the drugs longer than seven days is rarely necessary. Making patients aware of this is a necessary aspect of curbing opioid abuse, Kolodny says, adding that knowing about opioids’ addictive properties will encourage patients to keep these and other highly addictive drugs from piling up in their medicine cabinets.
According to the new guidelines, doctors should reassess the patient’s opioid use every three months to make sure the benefits outweigh the risks. If physicians suspect abuse, they should use evidence-based methods, like buprenorphine or methadone administration, to fight opioid addiction.
Patients should also take steps to remain advocates for their own care, according to Deborah Dowell, senior medical adviser for the Division of Unintentional Injury Prevention at the National Center for Injury Prevention and Control, part of the CDC.
Dowell said patients should ask:
- Is it necessary?
- What are the risks?
- How long should I expect to take this?
- What alternative therapies are available?
Addressing The Issue’s Complexity
Like most issues confronting health professionals today, there’s no clear-cut answer for when the risks supersede the benefits. This is the principal problem facing physicians – balancing an opioid’s relief of suffering with its capacity to effect mortality negatively. Typical reasons for prescribing opioids for chronic pain might be for conditions like herniated discs or even when patients report chronic pain with no immediately apparent underlying cause.
In these cases, doctors may prescribe opioids in an attempt to provide relief to an ailing patient. Some medical professionals disagree with the new recommendations, saying they may result in certain types of patients suffering needlessly.
Chris Hansen, president of the American Cancer Society’s Cancer Action Network, saw the CDC’s move as disregarding pain management for cancer survivors, who experience pain that affects their daily quality of life. He noted that the pain associated with cancer can last a lifetime, not just during the active treatment phase.
A Gray Area Of The Issue Regarding Addiction
While the guidelines give exceptions to those in active cancer treatment and those receiving palliative or end-of-life care, they don’t provide explicit instructions for those who have completed treatment and who continue to feel the effects of aggressive therapies. In these cases, physicians should talk about alternative therapies and consider prescribing opioids on a case-by-case basis, the document says.
The Response From Physicians
The CDC is facing some backlash from physicians themselves, who take exception to its characterization of opioid abuse as a doctor-driven epidemic. A scathing article on Medscape turned the buck back on regulating agencies. Some physicians insist that the current opioid epidemic was created by the government itself, which puts extreme pressure on doctors to deliver patient satisfaction. When patient satisfaction, delivered via survey, directly effects physician compensation, doctors feel the pressure to prescribe opioids for pain.
Other physicians are concerned about the fallout from such measures. One expressed concern about an increase in heroin-related deaths in the absence of addiction care infrastructure, while others speculated that patient suicides from untreated chronic pain might increase.
The Future Of Opioid Prescriptions In America
How these guidelines will ultimately affect prescribing behavior in the United States remains to be seen. Some physicians, validated by the guidelines, may take steps to reduce opioid prescriptions in their practice further, while others will continue to do business as usual.
Physicians are not beholden to these new guidelines, which are simply meant to inform primary care practice. While some physicians might balk at what they see as unnecessary regulatory intervention, others will take the recommendations to heart.