Do No Harm: CDC Guideline for Opioids and Chronic Pain

Many in the United States struggle day in and day out with chronic pain. Yet while the amount of pain reported by Americans has not changed since 2000, we now see four times the amount of opioids prescribed.
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Many in the United States struggle day in and day out with chronic pain. Yet while the amount of pain reported by Americans has not changed since 2000, we now see four times the amount of opioids prescribed. The result: a quadrupling of preventable deaths and an ongoing opioid overdose epidemic. It's happening all over the country, in our largest cities and smallest towns; to our parents, children, siblings, friends, neighbors and co-workers. And we can prevent this devastation by safer prescribing.

Every day, more than 40 Americans lose their lives to prescription opioids. We know of no other medication routinely used for a nonfatal condition that kills patients so frequently. Chronic pain is a public health concern in the United States and patients with chronic pain deserve safe and effective pain management. Prescription opioids have a role in pain management and can manage some types of pain.

But over time the number of patients receiving prescriptions for opioids - a class of drugs that includes hydrocodone, methadone, and oxycodone - has quadrupled since 1999. In fact, in 2013, health care providers wrote 249 million prescriptions for opioid pain relievers. That's enough for every American adult to have their own bottle of pills.

As patients and as doctors, we haven't weighed the risks of opioids -- addiction and death from overdose -- against the unproven and uncertain benefits of treatment of prescription opioids in the treatment of chronic pain. While evidence supports short-term effectiveness of opioids, there is insufficient evidence that opioids control chronic pain effectively over the long term, and there is evidence that other treatments can be effective with less harm.

When a prescription is necessary, we should try the safest and most effective medication first, and pain treatments that come with such risks should be the last option. Non-opioid therapies, physical therapy, cognitive behavioral therapy, and interventions like steroid injections, are alternatives that can lessen pain and improve function with far fewer risks than opioid analgesics.

Doctors - including me - were taught that patients taking prescription opioids for pain would not become addicted. We now know that was completely incorrect. Doctors want to do the right thing for their patients. They are concerned about opioid pain medication misuse, are worried about patient addiction, and want more training in prescribing opioids.

CDC's new "Guideline for Prescribing Opioids for Chronic Pain" provides recommendations to help primary care providers offer safer, more effective care for adult patients with chronic pain. The guideline is intended for use outside of active cancer treatment, palliative care, or end-of-life care. This approach will help reduce opioid misuse, abuse and overdose by weighing the uncertain potential benefits against the many known risks of these drugs.

The guideline will help primary care providers determine when to start opioids for chronic pain; give providers guidance about medication selection, dose, and duration, and when and how to reassess progress, and discontinue medication if needed; and help providers and patients--together--assess the benefits and risks of opioid use and address potential harms.

After reviewing the best available scientific research, consulting top experts, and considering more than 4,300 public comments, including input from over 160 organizations, CDC issued 12 recommendations to improve patient care and safety based on three main principles:
1)Opioids are not first-line treatment. Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
2)Start low, go slow. When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose - a "start low, go slow" approach.
3)Use caution and monitor. Providers should always exercise caution when prescribing opioids and monitor all patients closely.

Providers should also consider offering naloxone to patients prescribed opioids, especially those on high dosages, as the drug can save their life should they overdose. And, if the harms outweigh the benefits, providers should have a plan to taper opioids to a lower dose or to taper and discontinue them.

Those suffering from constant and debilitating pain may worry that their providers will no longer prescribe the medications they need to get through the day. However, the CDC guideline does not restrict providers' ability to prescribe medications. By following the recommended practices, providers and patients together can more confidently consider all treatment options, determine when and how to use opioids for chronic pain, and use other treatments alone or in combination with opioids to reduce pain and improve function.

The decision to prescribe or take an opioid is a momentous one. It is our hope that providers and patients will use the recommendations in this guideline to have an informed conversation about the best way to manage pain and set clear expectations for if and when to start opioids.

We have an obligation to act now to reverse the trends of opioid overdoses and deaths. With the guideline as one tool, we can change the course of the opioid epidemic in this country.

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