On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released a new set of guidelines for primary care physicians prescribing opioids in the context of chronic pain. The guidelines come at a time when deaths from prescription drugs are at an all-time high, and drug addiction has become a veritable epidemic that does not discriminate between rich and poor, old and young, rural and urban, male and female.
Primary care physicians write nearly 50% of all opioid prescriptions in the U.S. This category of drugs includes morphine, dilaudid, oxycodone and hydrocodone, and well-known brand names like Vicodin and Percocet. Healthcare providers wrote 249 million prescriptions for opioids in 2013, up from 116 million in 1996.
The guidelines recommend that physicians consider non-opioid alternatives as the first line of treatment. If opioids do become necessary, the guidelines urge physicians to start with the smallest possible dose of quick-release opioids, and to urine test patients to screen for other drug use to avoid potential drug abuse. When sufficient, the CDC encourages the use of physical therapy, over-the-counter pain medications, and behavioral changes in patients with chronic pain. The guidelines do not apply to cancer, palliative or end-of-life care.
“Today and every day this year, more than 40 Americans will die from a prescription opioid overdose in this country,” said CDC Director Dr. Tom Frieden in a press briefing. “Beginning treatment with an opioid is a momentous decision. And it should only be done with full understanding by both the clinician and the patient of the substantial risks and uncertain benefits involved. We know of no other medication that’s routinely used for a nonfatal condition that kills patients so frequently.
The drug abuse epidemic
In 2013, drug overdose surpassed car accidents as a cause of death in the U.S., killing 44,000 people. More than half of the drug overdose deaths were from prescription opioids. How did we get here?
According to Dr. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing (PROP), the current epidemic can be traced back to a drug campaign in 1996 that fundamentally changed how physicians treated chronic pain. That year, Purdue Pharma began promoting a new painkiller that they believed to be safer and less addictive (because of its slow-release mechanism): OxyContin. Following the campaign, drug sales of OxyContin jumped from $45 million in 1996 to $1 billion in 2000. Kolodny believes that the release of OxyContin led to a shift in pain management practices, a shift which underlies the quadrupling in opioid deaths between 2001 and 2014.
As time passes and death counts rise, the CDC has had to contend with a high-stakes challenge: reducing narcotic abuse while effectively treating chronic pain. Some physicians and patient advocates have expressed concern about the way the new guidelines could affect patients in practice, fearing that they could restrict access to narcotics for those that really need them.
“Given the recent surge in abuse and overuse of opioids, I think guidelines for how to prescribe these medications are crucial,” said Danielle Jonas, a social worker in the pediatric palliative care team at Children’s Hospital Los Angeles (CHLA). “However, as a pediatric palliative care social worker, I think it’s equally important to educate and inform the general population about the benefit of opioid use for symptom management, particularly in children and young adults with life-limiting illnesses.”
It is vital that we curb the rampant abuse of prescription narcotics, and these guidelines might be a step in the right direction. Providers’ prescribing practices may not rapidly and dramatically change, but raising awareness of the issue and of alternative care options could help to slowly turn the tide away from narcotic over-prescription.
The challenge the medical field must now face is finding less addictive but evidence-based replacements for the drugs so many patients with chronic pain rely on. Without more research to delineate alternate effective pain management protocols, individual patients may suffer during this transition as access to medication becomes more limited.
“Management of chronic pain is an art and a science,” writes Dr. Frieden in “Reducing the Risks of Relief – the CDC Opioid-Prescribing Guideline” in The New England Journal of Medicine. “The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits.”
It remains to be seen whether these guidelines will reduce drug abuse without jeopardizing quality of life in patients with severe pain. For now, a focus on awareness, education and research is the medical field’s best shot.
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