The new
CDC Guideline for Prescribing Opioids for Chronic Pain came down strongly against the use of opioids for chronic pain. If you're taking opioid pain killers such as such as Vicodin, hydrocodone and oxycontin expect things at the doctor's office to tighten up further. The report was squarely aimed at the primary care providers who prescribe most of these drugs.
The head of the CDC, Thomas Frieden stated that in most cases the risks of opioid use outweigh the benefits and that doctor's are largely to blame for what he called the "the prescription overdose epidemic"
"The prescription overdose epidemic is doctor-driven"
Frieden said. Recognizing that primary care physicians simply don't feel confident in their ability to prescribe opioid pain drugs correctly, the CDC focused its guidelines on them. The guidelines apply to anyone experiencing chronic pain after more than three months.
Significant Health Concern
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View attachment 1150 [/fright]The CDC reported that nearly two million Americans are either dependent on or are abusing prescription opioid pain relievers
The CDC estimates that 10 million Americans spend 9 billion dollars a year on opioid pain relievers, that about forty people die every day from prescription drug "abuse" - most of it unintentional, and that over 400,000 people visit emergency room because of prescription opioid drug overdoses.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," said CDC director Thomas Frieden. "We hope to see fewer deaths from opiates. That's the bottom line. These are really dangerous medications that carry the risk of addiction and death."
He said that many opiate pain-killers are as addictive as heroin and do little to control chronic pain.
The American College of Physicians largely agreed with the CDC effort stating that "many communities are being devastated by the adverse impact of opioid misuse." The problem is more complicated than taking too many painkillers. Patients who get hooked in opioid pain killers can go on to develop other dependencies.
The CDC did not state that opioids did not have
some role in managing chronic pain. It's clear that opioids can cause many problems but surprisingly little study evidence addresses how effective opioids actually are at managing chronic pain.
Huge Research Hole
Given the size of the problem it's incredible, however, how little research has been done. The CDC acknowledged that few good studies have assessed how effective opioids actually are treating long term pain.
The report also acknowledged that their recommendations are not based on strong studies. An AHRQ report found most opioid studies to be of low quality.
How insufficient is the evidence base? The CDC stated that
not one study has compared the benefits and harms of long term opioid use to other pain treatment options.
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View attachment 1149 [/fleft]The effects and benefits of long term opioid use is another major health issue that has mostly slipped between the cracks. It may be that the field has been ceded to the drug companies who have little incentive to fund studies that might show their products don't work very well long term. It's completely baffling sometimes how the NIH - tasked with improving the health of Americans - allocates its funding dollars.
Harms and Risks
Some trends, regarding harms, however, appear to be fairly clear:
- Higher doses of prescription opioids in general are associated with a greater risk of overdose.
- People taking high levels of opioids and getting them from several doctors are at increased risk of a fatal overdose
- Epidemiological studies suggest that using benzodiazepines with opioids may increase the risk of overdose.
- The risk of overdose is higher for patients with sleep apnea or other causes of sleep-disordered breathing, patients with renal or hepatic insufficiency, older adults, pregnant women, patients with depression or other mental health conditions, and patients with alcohol or other substance use disorders.
- The long term use of opioid pain killers may lead to sleep apnea because of decreased respiratory drive.
- Older adults may be at increased risk of bone fractures
- Opioids taken during pregnancy increase the risk of several birth defects
Opioid pain-killers are perceived to be cheaper than other options but the CDC reports that acetaminophen, NSAIDs, tricyclic antidepressants, massage therapy, COX-2 inhibitors, SNRIs, anticonvulsants, topical analgesics, physical therapy, and CBT all have lower mean annual costs.
The report said nothing, however, about the effectiveness of these options vs opioids.
Twelve Recommendations
In a nutshell the CDC recommends that other means of pain relief be used for chronic pain. It recommended that
- When opioids are used they should be combined with other therapies including other drugs and behavioral therapies.
- Realistic goals for pain relief should be set before pursuing opioid therapy, the risks outlined and a plan for getting off opioids, if necessary, be put in place.
- Immediate release (vs extended release) opioids should be used. The lowest effective dosage should be used.
- Opioids should be used to manage acute pain for at most days.
- Opioid effectiveness should be checked every few months.
- Before getting opioids patients should take a urine test to see of they are already taking them
- Doctors should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
- Buprenorphine or methadone in combination with behavioral therapies should be prescribed for patients with opioid use disorder.
It's clear that much work remains to assess the benefits/risks of opioid pain-killer use, when it is effective and when it is not and what alternatives are available.
See the
Full Recommendations here.
