In a rare move, the Centers for Disease Control and Prevention (CDC) issued new guidelines in March, advising physicians against prescribing opioid pain relievers to treat chronic pain.
It comes in the middle of heated debate between addiction professionals and pain specialists on how to deal with the prescription drug abuse epidemic in the United States.
According to the CDC, more than 28,000 Americans died from heroin and painkiller overdoses in 2014. That’s up from 16,000 in 2010. Every day, over 1,000 people are treated in emergency departments for misusing prescription opioids.
Dr Andrew Kolodny, the chief medical officer of the Phoenix House Foundation, has been campaigning for stricter rules on opioid prescriptions and welcomed the new guidelines. He told the Diane Rehm Show that he believes, “the guidelines are going a long way toward helping reduce over-prescribing.”
“What the CDC is saying is that the focus shouldn’t be on non-medical use. The focus should be on over-prescribing, that the medical community is fueling this epidemic by prescribing opioids for common conditions where they are not safe or effective,” Kolodny said.
The new guidelines offer exceptions for cancer patients and end-of-life care. When doctors determine that opioids are required in other situations, the CDC advises to prescribe the lowest possible dose for the shortest possible time period.
The CDC guidelines are not binding but are supposed to help physicians determine how to use opioids for chronic pain, which kind of painkiller to prescribe and how long to use it in order to minimize the risk of addiction.
Many patients suffering chronic pain fear that the unintended consequence of the new guidelines will be their doctor reducing or withholding the only medication they believe to be potent enough to alleviate their pain.
Chronic pain is a complicated condition and a large number of Americans are affected.
The 2012 National Health Interview Survey (NHIS) found that an estimated 25.3 million adults (11.2 percent) experienced pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain.
The Pain News Network puts the number at an astonishing 100 million Americans with experience of chronic pain. The Pain News Network also conducted a survey on the CDC guidelines among over 2,000 chronic pain patients. In the survey 67 percent disagreed with the suggestion that opioids are not the preferred treatment for chronic pain. Only 5 percent believed that addiction and overdoses will decline if the CDC guidelines are adopted. 89 percent of patients surveyed were very or somewhat worried that they will not be able to get opioid pain medication if the guidelines are adopted.
Health blogger Abigail Zuger recently looked at the “pain puzzle” and found that “we are in the middle of a giant paradigm shift in pain treatment.”
“Some past doctor, in the spirit of times gone by, once decided to eradicate their (patients’) pain with whatever it took. Now I am supposed to remove them from the substantial quantity of opioids that, apparently, was what it took,” writes Dr. Zuger in the New York Times.
Proponents of the new guidelines stress that it’s not about reducing access for people already depending on opioids but about not getting so many people dependent on opioids in the future.
Raymond Tait is Vice President for Research at Saint Louis University and served on a federal committee that helped draft the National Pain Strategy of the National Institute of Health. Tait told Saint Louis Public Radio that the issue is “not just opioids. It is opioids within the context of more effective management of chronic pain. A person who is entirely dependent on opioids as the one and only way of managing pain could be at a really tough crossroads at the time the prescription ends.”
One such patient was Christopher Baltz. He told the Daily Beast how he began using heroin after the opioid he had been prescribed for his chronic pain became difficult to obtain in Florida. Baltz was reportedly in his third year of being treated with a high dose of oxycodone following a serious traffic accident.
Then Florida cracked down on the state’s pain management industry in 2011, including the infamous “pill mills.” When Baltz showed up at his clinic, he discovered it had been closed. Within weeks he was buying heroin in Miami to self-medicate his pain.
Florida’s Prescription Drug Monitoring Program did result in a reduction of opioid prescriptions and other states have introduced similar laws. Massachusetts Governor Charlie Baker just signed tough new regulations into law, restricting the amount and potency of narcotic medications physicians can prescribe.
Dr. Peter Grinspoon is a primary care physician at a Boston clinic and teaches medicine at Harvard Medical School. Nine years ago, he was able to beat his own addiction to opioid painkillers. He thinks, the CDC guidelines are reasonable considering the disastrous nature of the current opioid epidemic. “The guidelines will help rein in over-prescription,” he told me, but “it is critical to understand that a lot of people rely on opiates for the treatment of their chronic pain, so we can’t just take people off the opiates, or make it difficult for the doctors to prescribe without coming up with an alternative.”
It’s a dilemma for doctors. “Every time, I prescribe opiates, I’m concerned they could be abused, or that someone could overdose,” says Grinspoon, “but if I don’t prescribe opiates I’m running the risk of not treating some very severe and real pain, which is cruel and inhumane.”
He has come across people who threatened to buy heroin or painkillers illegally when denied a prescription for opioids because they didn’t qualify for such medication. However, he would expect such behavior occasionally regardless of any CDC recommendations or state laws.
“We need alternatives to opiates, we can’t just stop prescribing them,” he says. “To a certain extent, the CDC guidelines are intimidating doctors not to prescribe medications that patients rely on. We need to arrive at some kind of common ground where we all work together to treat people’s pain while at the same time minimize the use of opiates,” says Grinspoon.
Raymond Tait agrees. “You need to bring a number of disciplines together so that each perspective can inform the others,” he told Saint Louis Public Radio. “The job is to look for alternative ways for people to manage pain as opposed to running away from opioids.”
If we don’t find that middle ground, we run the risk of pushing people who experience severe chronic pain on a daily basis down the road that Christopher Baltz took in Florida. This would be the worst kind of unintended result of guidelines issued to mitigate the opioid addiction crisis in America.