The federal government has published the first-ever national guidelines for prescribing opioid painkillers, such as OxyContin and Percocet, in an effort to halt the overuse of the highly addictive drugs.
The Centers for Disease Control and Prevention’s recommendations, published Tuesday in JAMA, encourage primary care doctors to offer other types of pain relief before prescribing opioids. They also recommend limiting patients’ drug supply.
“For the majority of patients, there are effective alternatives to the known, serious and all-too-often-fatal risks of opioids,” CDC director Tom Frieden said during a national press call this week.
From 1999 to 2014, more than 165,000 people died of overdose related to opioid pain medication in the United States. Deaths reached a record 28,647 in 2014, according to the CDC. However, some pain specialists have argued that there is a lack of evidence supporting the guidelines and fear they could prevent patients from getting the pain relief they legitimately need.
We talked to Anita Gupta, PharmD, DO, associate professor in the College of Medicine, about what the new guidelines could mean for physicians and patients.
Sarah Wenger, assistant clinical professor in the College of Nursing and Health Professions, also weighed in about how multidisciplinary pain management programs can offer alternatives to opioids and help wean people off of medication. Wenger leads the Power Over Pain program at the Stephen and Sandra Sheller 11th Street Family Health Services each Thursday morning. The psycho-educational program is tailored for minority and low-income patients experiencing chronic pain — many who are also addicted to painkillers.
What are the biggest takeaways from the new guidelines?
Having federal guidelines for medication management is unprecedented. The biggest thing about the guidelines is simply that they do not recommend using opioids as a main option to treat pain. Another significant recommendation is that doctors should give just a three-day supply of opioids after a surgery when, typically, patients get upwards of a one week or a one-month supply. That’s going to significantly shift what surgeons are currently doing.
I’ve already had surgeons ask me, “How do we address this? How do we treat patients for only three days? What kinds of drugs should we give?” The guidelines also recommend urine drug testing, which primary care doctors have been apprehensive to do. That puts a burden on their practice and may require more personnel.
Another significant guideline is that 15 mg of morphine is considered high-dose therapy. So physicians writing above that dose are going to be more closely monitored by pharmacies and insurance companies.
How do people get addicted to painkillers?
The majority of people who have chronic pain experience it after surgery. They begin taking medication as advised, but then months or weeks after, they are still taking them, and they are highly addictive. It happens all too often.
Do you think the new guidelines will be positive or negative for patients?
I think it’s too early too say. The CDC is basing the guidelines on what the evidence demonstrates. It’s going to put up challenges for physicians, but for the most part, I think it’s reasonable what the CDC wrote.
What needs to come along with the guidelines is an emphasis on communicating what these guidelines mean to patients. It is very important for physicians to take the time to discuss all of the risks and benefits of the treatment they are providing, and to make sure patients have a solid plan in place for managing pain before, during and after surgery.
Will physicians who do not follow these guidelines face repercussions?
The guidelines are meant to be a guide for physicians, but they’re not regulations. Ultimately, it’s up to the physicians’ discretion. But, in general, the standard of care has been created, so deviating from that puts doctors at higher liability. And the guidelines will probably have a significant ripple effect to insurance carries and the pharmaceutical industry.
Do you think the guidelines could prevent patients from getting the pain relief they legitimately need?
Unfortunately I think so. That is the reality. So many patients are worried about that.
But the good thing is that the CDC now requires a conversation to happen. Sometimes when I explain to patients, “This is what could happen when you use opioids,” they then don’t even want to use them. They say, “If it’s that bad, give me something else.”
I will be the first to say that physicians have been excessive with prescribing opioids, and we are under-utilizing non-opioid therapies.
What are other options for pain management beside opioids?
Things like combination therapy, meditation, massage, acupuncture and injections. There are so many non-opioid drugs and therapies, but we just aren’t using them. They take longer to work, and patients aren’t always patient. We know opioids are going to work quickly, so we’re in this situation now where they are over-prescribed and people overuse them.
We wouldn’t be in this situation that we are in now if we didn’t prescribe them so much in the first place. So again, it’s so important to have those detailed conversations and offer other solutions. Most people feel they just want to have no pain. They don’t really know what opioids are; they are just doing what the doctor says.
How did most of the patients who you see become addicted to painkillers?
Most of them started taking pain meds for acute pain, and when their pain did not improve and instead converted to chronic pain — often because of poor quality, limited or no initial treatment — they continued on the meds. Then they often needed more as their bodies accommodated to them.
When patients in the Power Over Pain group try to stop taking painkillers, what happens to their bodies, moods, etc.?
At first they are typically,very scared and reluctant to try because they are afraid their pain will become unmanageable. But they often feel better once they start in the group and also become more hopeful. I am not sure they ever stop feeling scared about it, but they are often relieved to have less side effects, like constipation and feeling groggy or not like themselves.
What are your general thoughts about the new CDC guidelines?
I think the recommendations are great. The risks of opioids really far outweigh the benefits, from what I’ve seen. One side effect of pain meds, for example, is constipation. If you have back pain, being constipated only makes that pain worse. I think just that side effect alone makes it not worth the benefits.
There are many patients addicted to painkillers who say they don’t have energy, which decreases their activity and leads to more pain. If you’re going to have acute pain and you treat it with narcotics, that’s fine. But if you have chronic pain, narcotics are not going to help.
I also think the psychology behind how you have these conversations is hugely important. You have to create a situation where you say, “This is good health care. Here are the risks,” instead of creating fear and rigidity around the drugs. If you make the situation scary, you’re going to make the situation more painful. The patient has to believe you have their best interest at heart.
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