In the United States, more than 100 million people live with chronic pain – that’s almost a third of the population. Over the past twenty years or so, increasing awareness about the issue of chronic pain among both doctors and patients has led to a rise in the number of prescriptions being written for opioids (narcotics) as a method of pain relief. Unfortunately, during this same time period, there has also been an increase in overdose related deaths and injuries, as well as a rise in levels of addiction. This has lead to quite a controversy concerning whether opioids are an appropriate form of treatment for chronic pain. On March 15, 2016, the Centers for Disease Control and Prevention (CDC) released the final version of its opioid prescribing guidelines. The release has intensified the outcry about this issue – but I think there are some important things to keep in mind when considering the guidelines.
Firstly, let’s consider the role of the CDC. The CDC’s mission is to increase the health security of our nation. As part of their pledge to the American people, the CDC bases “all public health decisions on the highest quality scientific data that is derived openly and objectively.” This means that the CDC has based its recommendations on the available scientific studies on the topic. I don’t think anyone is arguing that the scientific studies we have on this topic are sufficient – even CDC director Dr. Thomas Frieden has said “more research is needed to fill in critical evidence gaps regarding effectiveness, safety, and economic efficiency of long-term opioid therapy.” He continues “we are aware of no study that has compared opioid therapy with other treatments in terms of long-term (more than 1 year) outcomes related to pain, function, or quality of life.” So it is clear that more research into these topics is needed.
In the meantime, in accordance with its mandate, the CDC has used the best scientific data currently available to develop its recommendations. And I have to admit within that body of scientific data there are some disturbing statistics to consider. For example, one study showed that 1 of every 550 patients started on opioid therapy died of opioid-related causes a median of 2.6 years after the initial opioid prescription. And, for patients receiving higher doses of opioids, the proportion was as high as 1 in 32. Another alarming statistic is this one: in 2012 health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills. These numbers, of course, don’t prove that patients necessarily abuse or misuse their prescriptions or that all doctors are prescribing unnecessarily – but they do raise some questions. It’s part of the CDC’s role to respond to those questions and attempt to promote healthy and safe behaviors.
So what do the CDC guidelines actually mean for people living with the chronic pain of rheumatoid arthritis? Because while I am willing to venture that the majority of us would prefer to have safe, effective alternatives to using opioids (or even better – a cure!) some of us – myself included – sometimes need to rely on opioids to function or to maintain our quality of life. And we already know that the current regulations make it quite burdensome to obtain these necessary prescriptions, so it is easy to see how guidelines that “crackdown” on opioid prescribing would make us all feel a bit nervous.
Along those lines, there are a few important things to keep in mind. First, the guidelines are just that: guidelines. Despite the fact that they were issued by an official federal governmental agency, the suggestions contained in the guidelines are not laws. In fact, they are actually voluntary. So while the recommendations may have considerable weight, doctors are not even required to follow them. Secondly, the guidelines are only intended to apply to the prescribing behaviors of primary care physicians. This means that they don’t apply to your rheumatologist or any other pain care specialist you may be working with. Though there is occasionally an issue with accessibility, most individuals living with rheumatoid arthritis are being treated by specialists. Additionally, the use of opioids for spot treatment – for example, during flares instead of regular daily use – still fits within the framework of the guidelines. And part of what the guideline recommends is simply that doctors should talk to their patients about the pros and cons of the treatment, as well as continually evaluating to be sure that the benefits outweigh the risks. This, at least, seems to be a common sense recommendation that doctors ought to follow regardless of what kind of treatment they are recommending.
I will agree that some of the suggestions contained within the guidelines are a bit worrisome. For example, I don’t like the idea of my doctor potentially requiring a urine drug test, as that seems to come with the unpleasant presumption that I am not a trusted or responsible patient. And I do think there is a possibility that stricter guidelines could lead to an increase in stigma, which won’t be beneficial to chronic pain patients who need to rely on opioids. There has also been some criticism concerning the CDC’s lack of transparency during the process of developing the guidelines, as well as some frustration that the concerns of the patient community didn’t play more of a role in the process.
But overall I think this is a bigger problem than the CDC can realistically be expected to tackle on its own. The healthcare system as a whole – including scientists, governmental agencies, insurance companies, doctors, and patient organizations – need to work together to find real and long-lasting methods for helping the 100 million of us who live with chronic pain. And, perhaps most importantly, we need those methods to be accessible and affordable. While these guidelines may not be perfect, perhaps they can serve as a step in the right direction. It is my hope that we can all come together to continue advocating for better treatment solutions.