Opioid prescriptions could drop even further under updated US recommendations that encourage clinicians to seek alternative pain therapies, especially for acute conditions such as low-back pain.
The Centers for Disease Control and Prevention released Thursday substantial revisions to its Clinical Practice Guideline for Prescribing Opioids for Pain, updating recommendations on the use of opioids for acute pain, including tapering the use of opioids for patients who are already taking them. The initial guideline focused almost exclusively on chronic pain, but the version released Thursday also includes recommendations for treating shorter periods.
The changes follow a $13 billion tentative agreement from CVS Health Corp., Walgreens Boots Alliance Inc. and Walmart Inc. to settle thousands of lawsuits that accused the major pharmacy chains of of mishandling opioid painkillers.
The latest iteration updates and expands a document first released in 2016, the same year opioid overdoses accounted for 42,000 deaths, more than any previous year on record. While prescription opioids and misuse from these prescriptions have declined in recent years, the CDC said this class of drugs remains a common treatment for pain. Prescription opioids remained the most commonly misused prescription drug in 2020.
“We know that at least one in five people in the country have chronic pain. It’s one of the most common reasons why people present to their health-care provider,” Christopher M. Jones, acting director of CDC’s National Center for Injury Prevention and Control, said during a press briefing. “And the goal here is to advance pain function, quality of life for that patient population, while also reducing misuse, diversion consequences of prescription opioid misuse.”
Guidelines Meant to Aid Clinicians
The CDC issued the guidelines to help clinicians to work with patients to provide the safest and most effective pain care, such as recommendations on selecting opioids and determining dosages as well as deciding the duration of initial opioid prescription. The recommendations aim to support flexible, tailored, patient-centered care rather than a one-size-fits-all approach, Jones said.
“The guideline should not be used as a rigid standard of care or inflexible policy or law. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, or governmental entities,” he said. “The guideline provides information about a full range of options for pain management and encourages clinicians to work with other professionals and to provide the best evidence-based pain care possible.”
The science on pain care has advanced over the past six years, said Debbie Dowell, chief clinical research officer for CDC’s Division of Overdose Prevention.
“We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care,” she said.
Patients can treat most common acute pain using medicines such as non-steroidal anti-inflammatory drugs like ibuprofen or aspirin, or through non-pharmacologic interventions such as ice, rest, and elevation, the new guidelines said.
Those non-opioid therapies are “at least as effective” as opioids for treating conditions such sprains, low-back pain, kidney stones, headaches, and other acute pain that lasts less than a month, the CDC said.
The CDC still said it prefers non-opioid therapies for subacute pain, which lasts one to three months, and chronic pain, which lasts three months or longer.
“Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient,” the guidelines said. More than 100 million Americans experience chronic pain, according to the National Institute on Drug Abuse.
Guidelines Controversy
The CDC had set recommended thresholds for pain treatment in 2016 that were criticzed as too restrictive. Following the release of that guidance, roughly half of the states passed legislation that limited initial opioid prescriptions.
Agency officials said in a commentary in the New England Journal of Medicine, also published Thursday, that the earlier guidance had been misapplied, and they emphasized that individual physicians should use their professional judgment determining how and when to prescribe the painkillers, which can be lethal at high doses.
Misapplications of the policy, which meant inflexible application of recommended dosages and duration thresholds, have caused problems for patients. The authors noted health shortcomings that included undertreatment of pain, quick and drastic changes in opioid therapy dosages, withdrawal symptoms, and suicidal ideation and behavior.
The new guidelines recommend that doctors should carefully weigh benefits and costs of how they wean patients off opioids with a gradual reduction of doses to avoid withdrawal symptoms that could spur drug-seeking behavior. The agency emphasized that opioid therapy should not be changed quickly, saying longer-term opioid users will be more likely to tolerate slower processes of tapering off the opioids.
Alternative Therapies
The CDC also suggested alternatives to drugs, such as exercise, mind-body interventions, or massage therapy, but acknowledged insurers don’t always cover the cost of these.
“Access and cost can be barriers for patients, particularly persons who have low incomes, do not have health insurance or have inadequate insurance, have transportation challenges, or live in rural areas where services might not be available,” the guidelines said. “Health insurers and health systems can improve pain management and reduce medication use and associated risks by increasing reimbursement for and access to noninvasive nonpharmacologic therapies with evidence for effectiveness.”
When clinicians decide to prescribe opioids, they should opt for immediate release pills, and not the extended-release versions that last longer in the body and don’t have to be taken as frequently. The CDC wants clinicians to reserve extended and long-acting opioids for severe, continuous pain.
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