The Centers for Disease Control and Prevention (CDC) released their first-ever Guideline for Prescribing Opioids for Chronic Pain on March 15, 2016. The guideline offers much-needed guidance for primary care providers about when and how to start opioid analgesics, and steps to reduce the risks of opioids ― including addiction and overdose ― while treating their patients' pain. The goal of the guideline is to achieve a delicate balance in the tumultuous struggle between opioids' analgesic and addictive properties.
This balance of the opioid scale has been tipping between analgesia and addiction for thousands of years. We personally have witnessed the tipping by regulation, epidemiology, social forces and loud or bankrolled voices.
In advising the CDC as it developed this guideline, our responsibility was to weigh the utility of opioids for controlling pain against the dangers of addiction and overdose.
A push to treat pain aggressively
In the 1990s, a broad movement swelled to treat pain more aggressively. We remember the messaging we heard in medical school: "Don't be unsympathetic. If patients have real pain, they won't get addicted." These messages reflected a patient advocacy movement focused on pain management, guided by physicians trained in pain and palliative medicine, codified by federal agencies that created pain as a "fifth vital sign" and reinforced by pharmaceutical companies. This movement was effective; sales of prescription opioids quadrupled from 1999 to 2010.
Unfortunately, as we all now know, the 2000s brought a public health crisis of opioid addiction and overdose. Overdose deaths involving prescription opioids quadrupled between 1999 and 2014. This crisis necessitated a rapid public health response. However, insufficient evidence has been amassed about how and when to safely prescribe and stop prescribing opioids, and different factions of experts have disparate perspectives about how serious the problem is and ways to address it.
A conflict of experts
The two expert groups at the poles of this debate are physicians trained in pain and palliative care (whose priority is to reduce pain and suffering) and addiction specialists (whose priority is to prevent and treat addiction). Unfortunately, the discourse in this field has had two extremes: a pain and palliative care perspective that lacked understanding about the serious risks of addiction, and an addiction specialist perspective that lacked understanding about the serious risks of debilitating chronic pain. We believe that the multidisciplinary, fractured nature of the field of prescription drug abuse is one reason why it has been slow to be addressed, and why the problem got ahead of us.
Our guideline contributions
In creating its guideline, the CDC conducted a review of research and convened a broad panel of experts. We both served on the expert panels, helping interpret the evidence and advising about how to craft meaningful and appropriate recommendations based on the evidence. The existing research was insufficient to guide practice on a number of key issues, and all but one of the major recommendations were noted in the guideline to be based on low-quality evidence. Where evidence was lacking to guide practice, the CDC had to rely more on expert opinion. Even among experts, there was substantial disagreement. For example, experts disagreed on the appropriate dose or number of pills to prescribe, or whether and how often urine drug testing should be performed. Some of the disagreement reflects the tension between reducing pain and preventing addiction.
We believe that the final guideline is as strong as it can be at this time. Clinicians who read it and seek to follow it will treat their patients' pain and suffering AND be mindful of addiction. The CDC recommends that physicians:
- Treat chronic pain using a range of treatments rather than relying only on opioids
- Avoid, wherever possible, prescribing high doses of opioids, or prescribing opioids together with benzodiazepines, to reduce the risk of overdose
- Offer addiction treatment with medications such as methadone or buprenorphine when indicated
This guideline will save lives. The controversy and backlash about the process and the recommendations reflect the fractured nature of the field. As more evidence is amassed, and as expert opinion evolves, we expect that the specific recommendations will likely change. We would not be surprised to see updated guidelines over the next decade. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain is not the be-all and end-all, but it represents a huge step in the right direction.
Dr. Starrels is associate professor, department of medicine (general internal medicine) at Albert Einstein College of Medicine and attending physician, internal medicine, Montefiore Medical Group Family Care Center. Dr. Cunningham is professor, department of medicine at Einstein and associate chief of the division of general internal medicine at Montefiore Medical Center.
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This post was originally featured on The Doctor's Tablet, the blog of Albert Einstein College of Medicine.