The Centers for Disease Control and Prevention announced new guidelines for prescribing opioids for chronic pain on March 15. The agency had announced preliminary guidelines, which were open to scrutiny, public comment and debate, in December 2015.
After receiving recommendations from its advisory committee, experts and the pharmaceutical industry, the CDC has finalized its guidelines.
“More than 40 Americans die each day from prescription opioid overdoses, we must act now,” CDC Director Tom Frieden said in a press release. “Overprescribing opioids — largely for chronic pain — is a key driver of America’s drug-overdose epidemic. The guideline will give physicians and patients the information they need to make more informed decisions about treatment.”
The guidelines are for prescribing opioids for chronic pain, not including patients receiving treatment for cancer, palliative or end-of-life care. Pain is considered chronic if it lasts at least three months or longer than the time it takes for normal tissue to heal.
Three principles shaped the CDC’s 12 guidelines:
- Nonopioid treatment for chronic pain is preferred to opioid treatment — excluding cancer, palliative and end-of-life care.
- The lowest effective dosage should be prescribed when prescribing opioids.
- Doctors should prescribe opioids with caution and closely monitor patients.
Opponents of the guidelines include health care professionals and industry officials who believe the recommendations will make it more difficult for patients suffering from chronic pain to receive treatment.
“Doctors want to help patients in pain and are worried about opioid misuse and addiction,” said Dr. Debra Houry, director of the CDC’s National Center for Injury Prevention and Control, in a press release. “This guideline will help equip them with the knowledge and guidance needed to talk with their patients about how to manage pain in the safest, most effective manner.”
The CDC also developed tools for physicians to use when determining how to treat acute pain and chronic pain. Fact sheets, an opioid prescription checklist, a dosage calculator and other informational pamphlets are available online.
The Prescription Opioid Epidemic
Opioid painkillers grew in popularity in the 1990s and following decades, eventually bringing in more than $2 billion in annual sales, according to the New York Times.
As the number of prescriptions for opioids like oxycodone and hydrocodone grew, so did the number of people abusing the drugs. The number of people visiting the emergency department or dying from opioid overdose steadily increased, eventually reaching record numbers in 2014.
Pharmaceutical companies were ordered to make the drugs more difficult to abuse, and the manufacturers eventually developed drugs that could not be crushed, snorted or injected.
Experts have speculated that increased measures to prevent prescription drug abuse have led to recent rises in heroin addiction and overdose. Heroin is an illicit opioid that can relieve symptoms of opioid withdrawal when abused. However, some studies denounce the link.
Overview of CDC Guidelines
The CDC announced the new guidelines in a 50-page early release of its Morbidity and Mortality Weekly Report. The report was simultaneously published online in the Journal of the American Medical Association.
A summary of the guidelines:
Determining When to Initiate or Continue Opioids for Chronic Pain
- Nonopioid therapy is preferred to opioid therapy when treating chronic pain. When opioid therapy is used, its benefits should outweigh its risks.
- Physicians should develop treatment goals and a plan for discontinuation before beginning opioid therapy.
- Physicians should discuss the benefits and risks of opioids with patients before and during treatment.
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
- Immediate-release opioids are preferred to extended-release or long-acting opioids when beginning therapy.
- Physicians should prescribe the lowest effective dosage and reassess dosage regularly.
- When prescribing for acute pain, physicians should prescribe the lowest effective dosage and immediate-release opioids. In general, fewer than three days is usually sufficient and more than seven days is rarely necessary.
- Physicians should evaluate benefits and risks of opioid treatment for chronic pain within the first four weeks of beginning treatment and reevaluate benefits and risks at least every three months.
Assessing Risk and Addressing Harms of Opioid Use
- Physicians should evaluate risk factors for addiction and overdose before and during treatment. They should consider co-prescribing the overdose-reversal drug naloxone when risk factors for overdose are present.
- Physicians should regularly review the state’s prescription drug monitoring program to determine a patient’s opioid prescription history.
- Physicians should drug test for illicit drugs and other prescription drugs before beginning opioid therapy.
- Physicians should avoid prescribing opioids and benzodiazepines concurrently when possible.
- Physicians should assist with evidence-based treatment, usually including medication-assisted treatment, if a patient develops an addiction.