CDC Releases Guideline for Prescribing Opioids for Chronic Pain
Abstract
Clinicians have a major role to play in preventing, identifying, and treating patients with opioid addiction, experts say.
Last month, the Centers for Disease Control and Prevention (CDC) issued a guideline for clinicians who are prescribing opioids for chronic pain that is not associated with cancer, palliative care, or end-of-life care. The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment options for pain management and help to reduce the number of people who develop opioid use disorder or overdose or experience other adverse events related to these medications.
The CDC has issued a guideline to ensure that clinicians and patients consider safer and more effective treatment options for pain management.
“Addiction psychiatry has been concerned about how freely available prescription opioids have been over the past decade, which has contributed to the increase in deaths due to drug overdose and the rise in rates for opioid use disorder,” Frances Levin, M.D., chair of the APA Council on Addiction Psychiatry told Psychiatric News. “It’s good to see that the CDC is trying to come up with a strategy to handle a difficult issue,” continued Levin, who is also the director of the Division on Substance Abuse at Columbia University Medical Center.
According to the National Institute on Drug Abuse, U.S. health care providers wrote more than 200 million prescriptions for opioids in 2012, up from 100 million in 1998 and 190 million in 2008.
This increase may have been partially influenced by pressure from national authorities beginning in the 1980s for clinicians “to pay greater attention to pain,” Yngvild Olsen, M.D., M.P.H., medical director of the Institutes for Behavior Resources Inc. in Baltimore, wrote in an editorial published in the Journal of the American Medical Association in response to the CDC guideline.
In the editorial, Olsen noted that efforts to treat pain more effectively coincided with misleading marketing of prescription opioids by some manufacturers, who minimized the risks of misuse and addiction; additionally, “these efforts coincided with the introduction of patient satisfaction surveys tied to physician performance and reimbursement in some areas, including the assessment of pain,” she wrote.
“In retrospect,” Olsen continued, “this campaign occurred in the absence of substantial evidence for the long-term effectiveness of opioids in the treatment of persistent pain outside of active cancer and palliative care and without substantial training, understanding, and acknowledgment of addiction as a preventable, identifiable, and treatable disease.”
The CDC guideline includes 12 recommendations, which focus on when to initiate or continue opioids for chronic pain; appropriate opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. Here are four of the recommendations expected to have the most impact for psychiatrists:
Nonpharmacologic (for example, physical therapy, cognitive-behavioral therapy) and nonopioid therapies (for example, NSAIDs, acetaminophen, and some antidepressants) are preferred for chronic pain. The CDC recommends that clinicians should consider opioid therapy only if expected benefits outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. The CDC recommends that clinicians should evaluate the benefits and harms to patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.
Health care professionals should always exercise caution when prescribing opioids and monitor all patients closely. Because mental illness can affect pain and function in patients with chronic pain, the CDC recommends that clinicians use validated instruments to assess for anxiety, posttraumatic stress disorder, and/or depression that might help clinicians improve treatment outcomes.
Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder. For patients with problematic opioid use that does not meet the criteria for opioid use disorder, the CDC recommends clinicians should offer to taper and discontinue opioids.
“Although some of the items in the guideline are not supported by as much scientific evidence as we would like to appropriately make these recommendations [such as dosing], at least this is a good start in helping to address prescription practices concerning opioids,” Petros Levounis, M.D, M.A., an addiction expert and chair of the Department of Psychiatry at Rutgers New Jersey Medical School, told Psychiatric News.
“It is critical for decisions about pain management to be based on a thorough history and assessment of the patient and an individualized understanding of the physiological, psychological, and social factors that impact chronic pain,” APA CEO and Medical Director Saul Levin, M.D., M.P.A, wrote in a letter to the CDC in January in response to the then-proposed CDC guideline for prescribing opioids for chronic pain. “Throughout the guideline, APA suggests a greater focus on a patient- and family-centered approach that includes identifying patient values and preferences and respecting those preferences when clinically feasible,” he wrote.
The final guideline emphasizes the importance of discussions between clinicians and patients on the known risks and benefits of opioids prior to starting therapy. Such conversations are “critical so that patient preferences and values can be understood and used to inform clinical decisions,” the guideline notes. However, very little is mentioned about a family-centered approach to combat the current epidemic.
Olsen noted that “widespread adoption of the CDC’s recommendations in clinical practice would help reverse the epidemic of opioid overprescribing. However, as the CDC alludes to, success depends on simultaneously addressing significant gaps in the health care system,” such as the inadequate medical training for managing chronic pain and substance abuse and disparities in reimbursement for pain management and addiction treatment.
“I think it will be very important to start training health care professionals early in their careers about chronic pain and addiction,” Olsen told Psychiatric News, “including how to effectively talk and engage with patients, families, and communities about risk factors, screening, interventions, and treatment for both conditions.”
“As health care professionals, we need to demystify these conditions and accept that we have a role in preventing, identifying, and treating patients with opioid addiction; not turn them away,” she added.
Frances Levin added that clinicians should engage with health organizations and policymakers at the state and federal levels to implement necessary changes for treating pain and opioid addiction.
“Doing nothing is not an answer,” she said. “Hopefully the CDC recommendation will have a positive impact on the country as a whole, resulting in better patient outcomes and saved lives.” ■
