The Centers for Disease Control and Prevention (CDC) has proposed new guidelines for prescribing opioid painkillers, a class of highly addictive drugs used to treat severe pain.
The guidelines, which are still in draft form, remove a previous recommended ceiling for opioid dosage—guidance that was met with backlash at the time. Now, the guidelines encourage doctors to use their best judgement when prescribing opioids, and to use "nonopioid therapies" as a first intervention.
The new recommendations—a 229-page document—are the first extensive updates to the CDC's prescribing guidelines for opioids since 2016, and in them, the CDC makes clear the risks of opioid addiction and the growing epidemic. In 2019 alone, an estimated 10.1 million people aged 12 or older misused opioids, according to data from the US Department of Health and Human Services (HHS)—and 9.7 million of those people misused prescription pain relievers.
Below, you'll find everything you need to know about the new proposed guidelines and what they mean for chronic pain sufferers and the addiction community.
How do the new guidelines differ from previous recommendations?
The CDC's 2016 guidelines heavily discouraged doctors from prescribing opioids. The new guidelines recommend that doctors use other nonopioid alternatives as much as possible—but they stress that doctors can prescribe opioids in certain situations, when they see fit.
Those new nonopioid therapies that doctors are encouraged to try for chronic and acute pain management in patients include:
- Over-the-counter medications like ibuprofen and acetaminophen
- Prescription medications like gabapentin
- Physical therapy
- Massage
- Acupuncture
"Gabapentin has a great role in neuropathic pain," Jamie Alan, PharmD, PhD, associate professor of pharmacology and toxicology at Michigan State University, tells Health. "Physical therapy also has a huge role in pain management. There are many other choices instead of opioids that are very useful for pain."
However—as the new guidelines suggest—there's no one-size-fits-all way to treat chronic pain, and it's important to take different approaches Krishna Shah, MD, an interventional pain medicine specialist and assistant professor of anesthesiology at Baylor College of Medicine, tells Health. "When treating pain with physical therapy, gabapentin, acetaminophen, NSAIDs, and muscle relaxers, we are treating different receptors and aspects of pain," he explains. "If we can attack pain from multiple different angles, we would have the best outcome in managing it. When doctors determine that opioids are needed, the CDC recommends starting patients at the lowest dose possible."
The proposed new guidelines are welcomed by those who felt the previous ones were too harsh for those who suffer from chronic pain. "The initial guidelines, although great, were considered too restrictive," Dr. Shah says, noting that they included things like limiting the use of opioids for acute pain to three days or avoiding opioid dosage to about 90 milligrams. Now, under the new guidelines, "if a surgery or an episode of acute pain requires a longer short-term course of opioids, that would be considered acceptable," he says. "If formally accepted, we will no longer see the one-size-fits-all approach."
It's also important to note that, while the guidelines are technically just recommendations, they tend to influence insurance coverage and even state law, Jeanmarie Perrone, MD, director of the Division of Medical Toxicology and Addiction Medicine Initiatives at Penn Medicine, tells Health.
"The previous round of guidance was subject to possible misinterpretation, including insurance companies limiting opioids for people with chronic pain," says Dr. Perrone. "The goal with the new guidance is judicious opioid prescribing with an emphasis on alternative medications for pain." The idea behind it, she says, is that if patients find an alternative to opioids that works for them, there may be a decrease in opioid addictions.
Will opioids still be used in some cases?
The new guidance stresses that opioids are still needed in certain circumstances, including end of life pain, severe pain caused by cancers, bad burns, and certain broken bones.
"Opioids still have a role in managing pain," Whitney Luke, MD, a pain medicine specialist at The Ohio State University Wexner Medical Center, tells Health. "They are often used for patients with active cancer and cancer–related pain. They may also be used sparingly for patients who have exhausted other pain management options."
In addition to starting patients off on the lowest dose possible, the new guidelines encourage doctors to prescribe immediate-release pills, as opposed to long-acting pills, when possible. As the name suggests, immediate-release pills are effective more immediately after being taken, but their effects wear off quicker than those of long-acting pills.
What should you do if you’re taking a prescription painkiller?
If you're already on a prescription painkiller, Dr. Luke recommends talking to your doctor about the risks and benefits of your medication, and asking about alternatives that can help. "A referral to an interventional pain physician could also be offered to see if there are any interventions such as injection therapy that may help with their condition," she says.
Doctors are supposed to be keeping an eye on you if you are on a prescription for an opioid medication, Dr. Luke says. "If someone is on opioid medication, their doctor should be meeting with them regularly, at least every two to three months," she says. "They should be assessing pain relief with the medication as well as if the medication is improving their functional status. They should also be assessing the patient's risk of overdose and if they are taking the medication as prescribed."
Any doctor that prescribes an opioid should first check to make sure it won't interact with another medication their patient is on, explain how to take the medicine safely, confirm that they aren't abusing it during follow-up appointments, and set realistic expectations about stopping the medication when possible, Dr. Shah says.
The reason for all of these layers of protection is the concern that opioid use will lead to dependence, tolerance issues, and addiction, Dr. Perrone says. "There is concern that prescription opioid use has spurred more opioid use," she says. "Some people like the feeling of being on opioids and, if that prescription runs out, they may try to buy something on the street. But these drugs are often not what people think they are—and that's where we see a lot of fatal overdoses."
If you've had a prescription for opioid medication that's run out, and you feel like you can't stop taking the pills "this could suggest that you need treatment for a substance use disorder," Alan says.
If you or someone you know struggles with substance abuse, seek help by contacting the national helpline for the Substance Abuse and Mental Health Services Administration (SAMHSA) at 800-662-HELP (4357).
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