Dissecting the new opioid prescribing guidelines

The U.S. saw about 165,000 deaths from overdoses of prescription opioid medications between 1999 and 2014. The same time period saw a quadrupling in the number of opioid prescriptions written, even though the amount of pain Americans reported remained virtually unchanged.

            These were among the developments that led the Centers for Disease Control and Prevention (CDC) to issue, in March, an updated guideline for prescribing opioids for chronic pain treatment. The guideline’s authors discussed the 12 specific recommendations contained in it, and the evidence behind them, before an overflow crowd at the American College of Physicians 2016 Internal Medicine Meeting in Washington, D.C.

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            The previous guidelines “don’t incorporate the latest scientific evidence, especially regarding dosage and [overdose] risk, so we believed there was a need for clear consistent recommendations that could help provide guidance to providers and improve care,” said Tamara Haegerich, PhD, deputy associate director for science in the CDC’s National Center for Injury Prevention and Control. The new guideline is intended for use in outpatient settings for patients 18 and older experiencing acute or chronic non-cancer pain.

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            When a preliminary version of the guideline was published in the Federal Register it received more than 4,500 comments, Haegerich said, the most ever for the CDC and evidence of widespread concern about opioid overuse.

            Among the other findings of the clinical and contextual reviews that preceded the new guideline, Haegerich said, were:

·      Between 3% and 26% of patients at primary care practices present with evidence of opioid use disorder;

·      Up to 20% of patients presenting to PCP offices with chronic pain not related to cancer receive an opioid prescription;

·      Primary care providers account for about half of the opioid prescriptions written in the country, even though the majority of providers admit that they are concerned about the effect of opioids and not confident about their ability to prescribe them safely; and

·      Effective non-pharmacological and non-opioid treatments exist for treating chronic pain. The former include exercise, behavioral therapy and interventional procedures, while the latter include nonsteroidal anti-inflammatory medications, acetaminophen, and some forms of anticonvulsants and antidepressants.

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In addition, “we found abundant evidence of overdose risk that’s dose-dependent, and identified factors that increase risk for harm including pregnancy, older age, mental health disorders, and sleep-disordered breathing,” Haegerich reported.

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The guideline’s recommendations fall into three broad categories: determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. These were addressed by Roger Chou, MD, FACP, professor in the department of internal medicine at Oregon Health and Science University; and Deborah Dowell, MD, MPH, a senior medical advisor in the CDC’s National Center for Injury Prevention and Control.

Chou stressed the importance of first trying to address pain with non-opioid therapies, and using a “start low, go slow” approach if they physicians do prescribe them. In addition, he said, it’s important to match the quantity of medications prescribed to the expected duration of the pain. “Don’t prescribe additional amounts ‘just in case,’” he advised.

Dowell stressed the importance of reviewing a new patient’s history with use of controlled drugs in the context of avoiding combining medications that could be dangerous or even lethal. “Remember that this as an opportunity to present potentially life-saving information to patients,” she said.