The CDC issued the "CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016" earlier this month with 12 recommendations, including:
· Nonopioid therapy is preferred for the treatment of chronic pain and opioids should only be used when benefits outweigh risk to the patient
· Before starting an opioid therapy, physicians should establish goals with the patient and consider how opioids will be discontinued
· Physicians should only prescribe the lowest effective dosage of an opioid when starting a new therapy and reassess risks of upping the dosage
· An opioid therapy should be revisited every three months, or more frequently, to evaluate harms and benefits of the regimen
"When the government and regulatory agencies get involved there are a lot of people who give input with tangential knowledge of the subject, like the old parable of the blind men and the elephant. Interventional pain physicians haven't given input yet and we can offer effective treatment," says Scott Glaser, MD, DABIPP, President and co-founder of Pain Specialists of Greater Chicago. "Opioid use and consequently abuse is at epidemic levels because individuals in pain are looking for answers and opioids are effective short term and convenient. Unfortunately, they have huge risks and don’t work long term. Interventional pain management specialists understand this and we are always treating the sources of pain with minimally invasive procedures that provide high quality relief for months or years which can be repeated if the pain returns. It is the safest, most efficacious and cost effective treatment for pain."
Here are 10 things to know about the new guidelines:
1. Prescriptions and sales for opioid pain medications have quadrupled since 1999, according to the CDC. Overdose deaths related to prescription opioids took 165,000 lives from 1999 through the present.
2. Forty-plus people die every day with prescription pain killers as the sole or contributing cause. "Patients take these potent painkillers and get used to them and think they'll be fine, but long term, those painkillers can be as risky as surgery," says Dr. Glaser. "We can do image guided joint injections and nerve blocks or other interventional pain procedures and the patient will experience high quality pain relief for months or years over 90 percent of the time."
3. Short acting opioids such as hydrocodone and oxycodone are now only indicated for severe pain. They used to be indicated for moderate or severe pain, according to Dr. Glaser. “This is a subtle change but will likely be exploited by insurance companies to reduce reimbursement for these medications effecting people who truly need stronger opioids.”
4. Non-narcotic analgesics use is routinely recommended prior to using narcotics.
5. The FDA boxed warning alerts prescribers to the risk of misuse, abuse, addiction, overdose and death associated with the drugs, as well as the risk of neonatal opioid withdrawal syndrome if taken during pregnancy.
6. New warnings on both extended release and short acting opioids include information about the risk of drug interactions that can lead to serotonin syndrome as well as effects on the endocrine system, including adrenal insufficiency, and on decreased sex hormone levels.
7. It is suggested that physicians carefully assess the risks and benefits of continued therapy when daily doses hit 50 morphine milligram equivalents or more, and they should avoid increasing the dose to 90 MME per day or higher.
8. For acute pain, the guidelines recommend no more than three days worth of opioids should be prescribed.
"There are some people who have pain that is effectively and safely treated with opioids and if their PCPs stop prescribing opioids, those patients will be driven to us," says Dr. Glaser. "The CDC recommends only three days of pills for acute pain, but acute pain comes in so many different forms. It can be due to bone issues, a strain, back problems or a herniated disc. To lump all these syndromes together and arbitrarily say they will not need strong pain medications after three days will drive up ER and acute care visits."
9. Many groups, including the American Cancer Society, have grave concerns about the CDC guidelines and are calling for them to be withdrawn. The evidence behind the guidelines was limited and low quality. They also question the methodology and lack of transparency of the entire process.
10. More than 50 percent of opioid prescriptions are prescribed by primary care physicians. “This is where the opportunity to change the paradigm lies, when acute pain persists. This is the time for interventional pain management physicians to step up to the front of the continuum of care," says Dr. Glaser. "We know surgery and narcotics can be dangerous and we understand the long term risks of both. It's time for interventional pain doctors to take the reins and accept responsibility for patients in this subacute phase as their pain goes from acute to chronic. We have all the tools and knowledge to treat these pain syndromes minimally invasively and keep patients healthy and away from surgery and excessive narcotic use."
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