The New Opioid Prescribing Guideline: Flawed and Worrisome

The Centers for Disease Control and Prevention released their new “Guideline for Prescribing Opioids for Chronic Pain” on March 15.

The guideline targets opioid pain medications prescribed by primary care physicians to chronic pain patients 18 years old and older. They include opioid analgesics such as hydrocodone (Vicodin, Norco), oxycodone (Oxy-Contin), oxymorphone (Opana), methadone, and fentanyl. Why? The CDC’s aim is to ensure that patients “have access to safer, more effective chronic pain treatments while reducing the number of people who misuse, abuse, or overdose [on] these drugs.”

The guideline encourage primary care doctors to avoid prescribing opioid painkillers whenever possible, and to prescribe less risky, non-opioid pain relievers instead. If physicians feel they must prescribe opioids, then they should do so in the smallest dosages and for the shortest amount of time possible, and they should avoid using them for chronic pain, since studies show they don’t work on chronic pain over the long term.

The guideline also encourage PCPs to prescribe alternative pain-relieving modalities, such as cognitive behavior therapy, physical therapy, meditation, a healthy diet, and adequate exercise, instead of opioid analgesics.

Well, it all sounds pretty noble, right? Why be upset that our government wants to protect us from possible dependence, addiction, and even death? I wouldn’t be upset myself, except that there are real problems associated with the new guideline. My honest opinion? It’s a panicky, ill-thought-out reaction to an overhyped, media-driven, poorly researched "prescription opioid epidemic."

But before I delve into all that, let me say this: don’t panic. Keep in mind that the guideline is just that: a guideline. It isn’t a law or even a rule (yet). Following it is entirely up to your family doctor, who’ll presumably make her decision based on your health, your legitimate need for opioid analgesics, and your circumstances. Will your rheumatologist, orthopedist, or pain specialist follow it as well? Maybe, maybe not.

OK, then. Let’s jump in. Chronic pain, by the CDC’s definition in the guideline, “is pain lasting longer than three months or past the time of normal tissue healing.” They further state that opioids prescribed for the treatment of cancer, for palliative care, or for end-of-life care are “outside” the focus of the guideline.

I believe this is an important distinction.Palliative care is, according to the National Institutes of Health, “treatment of the discomfort, symptoms, and stress of serious illness. It provides relief from distressing symptoms, including pain [my emphasis], shortness of breath, fatigue, constipation, nausea, loss of appetite, and problems with sleep. It can also help you deal with the side-effects of the medical treatments you’re receiving.”

It’s certainly arguable that rheumatoid disease is a “serious illness” that causes a distressing amount of pain, along with several of the other symptoms named by the NIH, including fatigue, loss of appetite, and pain-related insomnia. Given that, RD would seem to fall, quite legitimately, under the palliative care umbrella, allowing us all to breathe a collective sigh of relief.

However, palliative care is a new specialty, meaning that palliative care physicians are scarce. I find that, in itself, a little surprising given that treating discomfort, symptoms, and stress is the very core of doctoring in the first place. And so far, health insurance companies don’t always cover palliative care (and there are varying definitions of what, exactly, it constitutes). These are real obstacles to the palliative care argument, but it’s worth making. I think it offers hope for positive change in the future.

The CDC developed the new opioid prescribing guideline in reaction to research and reports of a sharp rise in the number of opioid overdose deaths over the last several years. That seems reasonable, but unfortunately, the research and reports are seriously flawed.

The research numbers include all opioid-related deaths.

That is, the very small percentage of legitimate, responsible chronic pain patients who died of overdoses between 1999 and 2014 were lumped in with all the other prescription opioid deaths, such as those of non- or questionable pain patients who misused or abused the drugs. Also included in the 165,000 opioid overdose deaths during those years were those unfortunate souls who died from other illegal opioids, such as heroin. These tragic opioid deaths, as you might expect, constitute a much, much larger percentage of the whole.

Also not considered in the research and reports: how other drugs (prescribed or not), alcohol, or other circumstances may have contributed to the overdose deaths in any of the populations. For instance, some types of anti-depressants, tranquilizers, and muscle relaxers interact dangerously with opioids, which are already well-known to sometimes depress breathing in higher doses. Alcohol is also terribly risky in combination with opioids, prescribed or illegally procured. To that end, prescription opioid bottles include bright red or yellow stickers printed with bold-faced warnings against alcohol consumption while taking them.

Yet another aspect of the opioid overdoses not considered in the research is that some of them may have been intentional; that they were suicides, not accidents. These are heartbreaking and tragic, but no-one investigated.

Now, let’s look at the studies referred to in the guidelines that indicate that opioid pain medications don’t work for chronic pain. First, there have been very few of them actually undertaken regarding the efficacy of opioids in chronic pain settings. Those few were small or generally inconclusive.

But that doesn’t matter. The CDC’s argument seems to be that because chronic pain patients often become dependent (as opposed to addicted) and sometimes need increasingly large doses of opioids to manage their pain, these dangerous drugs obviously don’t work. The CDC asserts that taking them longer than a couple of months may cause dependence, addiction, and/or accidental overdose and death. And if that’s not enough, addicted chronic pain patients may just switch over to the big H, heroin. That’s another scary epidemic to blame on prescription opioids (as opposed to the societal problems of a weak economy, low-paying jobs, pervasive poverty in many parts of the country, and the relative overall cheapness of street heroin).

These reports, taken seemingly without question by the government, the CDC, and the media, have generated a lot of concern (read worry, consternation, and fear) among those of us who take opioid analgesics legitimately and responsibly to relieve debilitating, disabling chronic pain caused by rheumatoid disease and other chronic and incurable illnesses.

The fact is that prescription opioids, taken with care and as directed, allow us to live more normal, productive lives, and while they don’t totally relieve our pain, they do make it far more bearable. And while we may, indeed, be physically dependent on them, that doesn’t equal addiction or any of the awful connotations associated with the word in this country.

Here’s the thing: Responsible, legitimate chronic pain patients have, since 2014 (and in many cases, even before then), already been required to jump through appallingly restrictive, government-imposed hoops to receive physician-prescribed opioid pain medications. The restrictions have forced them to endure multiple doctor visits (and insurance co-pays) simply to receive hand-written opioid prescriptions that cover just a one-month supply at a time, strictly enforced. The restrictions have also made it harder for patients to get the prescriptions filled at their local pharmacies, which often question the prescriptions themselves, refuse to fill them, or, because the government has restricted the amount of opioids the pharmacy can stock, simply don’t have enough to go around. This forces chronic pain patients to pharmacy-shop, often at great inconvenience and while enduring terrible pain. In addition, many physicians now require random urinalysis tests and pill counts to ensure that their patients are taking their drugs exactly as prescribed. This is humiliating and demeaning—and it requires even more lab-and-office visits (and co-pays).

And if that’s not enough, the existing restrictions and now, the new CDC guideline, have placed a heavy, undeserved, and highly public “addiction” stigma on anyone afflicted with a chronic illness who needs opioid medications to live, function, and work normally while coping with chronic pain.

There’s more, such as the fact that the CDC didn’t consult chronic pain patients during the guideline development process until there was a large public outcry. In addition, the task force that developed the guideline included several outspoken and media-savvy physicians associated directly with a chain of commercial addiction treatment centers. But I’ve said enough already. You can read more about all of my concerns in the references below.

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