In addition, the CDC published a guide to prescribing opioids for chronic pain.1 From much of the media coverage of the guide, it is easy to infer that its recommendations represent a revolutionary departure from the guidelines of other professional organizations; that its goal is to warn doctors not to prescribe opioids for patients who need them; that it places burdensome restrictions on doctors; that it prevents doctors from prescribing opioids for acute and cancer-related pain; and that in a mythical battle between those health professionals who treat pain and those who treat opioid abuse, the latter won.
What the directive actually says
All of these are misunderstandings. First, compliance with the directive is purely voluntary and while it includes a general practitioner checklist (the target audience for the directive) to be used in prescribing opioids, its use is in no way compulsory. The extent of the misunderstanding of the policy is illustrated by a story in the New York Times of a family doctor who said he needed to “go through an extensive prescribing checklist” and “limit opioid use.” 2
The guideline makes it clear that it should apply to patients with chronic pain – not to patients with acute pain. It alerts doctors that many patients being treated with opioids for acute pain will use opioids when the pain becomes chronic. Therefore, we should think more carefully when deciding whether and for how long these patients actually need an opioid. The policy does not apply to people being treated for cancer or receiving end-of-life treatment or palliative care.
What does the directive actually say? I encourage you to read the full guideline, or at least the detailed summary of their recommendations, or even the one-page checklist of them.3,4
Many psychiatrists do not prescribe opioids for pain. However, as the directive is relevant to the treatment of opioid use disorders, I believe it is important that all mental health professionals are informed of its content.
The guideline contains 12 specific recommendations. This includes evaluating the effects of treatments on functional levels in addition to pain; set clear goals for their use; Discussing the risks and benefits of their use with patients; Prescribing the lowest effective doses; regular reassessment of the benefits and harms of drugs; and using government surveillance programs for prescription drugs to be included. The lack of knowledge of many doctors about the treatment of chronic pain in general and the use of opioids in particular shows that even some of them are needed. It is terrifying that someone would prescribe opioids for chronic pain without realizing it all.
The guideline recommends trying non-pharmacological and non-opioid therapies for chronic pain before starting opioids. It should be noted that while there is little research showing the benefits of opioids for chronic pain, there is more research showing the benefits of these other approaches. We know that physical therapy, occupational therapy, and cognitive behavioral therapy can be very useful. When it comes to medication, much of the public, and unfortunately many health professionals, still believe that opioids are always the best analgesics, although the drug of choice is very dependent on the type of pain.
The guideline recommends always starting patients on immediate release / short-acting (IR / SA) opioids instead of extended-release / long-acting (ER / LA) opioids. This is useful for a number of reasons. ER / LA drugs take several days to achieve maximum analgesic effects, and dose titration with IR / SA drugs is much easier. If the patient has never taken the drug before and an adverse event occurs, then it is better to clear the drug from the body faster. Finally, there is little evidence that ER / LA opioids are more beneficial than the IR / SA opioids.
The guideline also notes the importance of assessing the risk of abuse in all chronic pain patients for whom opioids are considered. Little has been found to support the predictive value of screening tools such as the Opioid Risk Tool (ORT) and Screening and Opioid Assessment for Pain Revision Patients (SOAPP-R). Aside from an increased risk of opioid abuse disorder in patients with a history of substance abuse or mental illness, we really lack anything that could help us predict which patients will ultimately abuse opioids. For this reason, regular assessment of each patient is required at regular intervals, even though it may require time and effort on the part of the prescribing physician.
I am very happy that the guideline warns against prescribing opioids to patients taking benzodiazepines. Although we know that taking these two classes of drugs at the same time significantly increases the risk of death from overdose and that benzodiazepines reduce the analgesic effects of opioids, they are still often prescribed together.
Two recommendations give cause for concern
There are two recommendations in the directive that I have concerns about as there is no evidence to support them. The first is the recommendation for urine drug testing (UDT) before starting opioid therapy and using it at least once a year. I have no problem with UDT once its limitations are recognized. I worry that doctors may only rely on it to determine if patients are misusing the drugs or misleading which drugs they are using.
Most primary care bureaus are not set up for patients delivering what anyone thinks is close to valid samples. Since we are trying to catch the cheaters, we should assume that these are the ones who will try to play the system. If it’s their first time going to a new doctor looking for an opioid prescription and worry that their UDT will reveal something that makes the doctor reluctant to give the prescription, they could potentially provide a clean sample from someone else. The guideline recognizes that there is as yet no literature showing that UDT reduces the risk of patients misusing prescription opioids.
I am also concerned about the recommendation to use buprenorphine or methadone for opioid disorders. This recommendation is fine for those patients who developed this disorder for nonmedical reasons after using opioids. However, there is no evidence to suggest that it applies to patients who were treated with opioids for pain and subsequently had problems with them, i.e. using iatrogenic opioid disorder.
The guideline notes that studies of these treatments primarily included offenders with a history of illicit drug use – not those who started using these drugs for pain. However, I find it worrying that a comment on the CDC’s director, Dr. Thomas Frieden, co-authored guideline simply states, “In patients who become addicted to opioids, treatment with methadone, buprenorphine, or naltrexone improves outcomes,” without acknowledging the lack of evidence for people with iatrogenic disorder.5 Another recently by the director of the National Institute on Drug Abuse, Dr. Nora Volkow, co-authored article, also states that there is iatrogenic opioid dependence, but makes the same treatment recommendations
Also, these two articles and the directive take little account of the fact that the fight against opioid abuse is unlikely to lead to a successful outcome without treating the pain. It is unfortunate that the directive and two of the federal government’s leading experts on health care fail to recognize this. I believe this reflects the fact that most pain specialists know very little about substance abuse and few substance abuse experts have much knowledge about pain management.
I have one final concern about the policy. I fear that it, and probably in many cases the one-sided checklist alone, may be viewed by many as a substitute for formal education about pain management and prescribing opioids that so many doctors lack. That fear was compounded by the White House’s announcement that 61 of the country’s 172 MD and DO schools have agreed to “require their students to complete some form of prescription education,” according to CDC policy.7
While I welcome this announcement, especially because many doctors prescribe opioids without adequate training, it depends on the type of training. To truly follow the guideline, prescribers need to be aware not only of how opioids are properly used, but also of the other treatments available for chronic pain and the appropriateness of each for individual patients. I needed a year-long pain management scholarship to learn this. I don’t think it can be taught in the few hours medical schools are likely to afford.
Until medical schools finally recognize that chronic pain is a complex problem and incorporate education every four years, there is little improvement in pain management.
References:
1. Centers for Disease Control and Prevention. CDC’s Guideline on Prescribing Opioids for Chronic Pain: USA, 2016. MMWR. 2016; 65: 1-49.
2. Hoffman J. Pain sufferers and a doctor who has to restrict medication. New York Times. March 17, 2016; A1.
3. Dowell D, Haegerich TM, Chou R. CDC Prescribing Opioids for Chronic Pain – USA, 2016. JAMA. March 2016; [Epub ahead of print].
4th Centers for Disease Control and Prevention. Checklist for Prescribing Opioids for Chronic Pain. http://www.cdc.gov/drugoverdose/pdf/PDO_Checklist-a.pdf. Accessed April 6, 2016.
5. Frieden TR, Houry D. Reducing the Risk of Relief: The CDC’s Policy on Prescribing Opioids. N Engl J Med. March 15, 2016; [Epub ahead of print].
6th Volkow ND, McLellan AT. Opioid Abuse for Chronic Pain: Misconceptions and Mitigation Strategies. N Engl J Med. 2016; 374: 1253- 1263.
7th White House Press Office. Fact Sheet: Obama Administration Announces Additional Measures To Combat Prescription Opioid Abuse And Heroin Epidemic; March 29, 2016. https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-address. Accessed April 6, 2016.
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