In response to the opioid epidemic that has swept the country, the Centers for Disease Control and Prevention released long-anticipated guidelines on prescribing opioid painkillers such as OxyContin and Percocet.
They were published Tuesday in JAMA, the Journal of the American Medical Association.
The advice is aimed at primary care physicians, who prescribe nearly half of the opioid painkillers consumed in the U.S. The guidelines aren’t intended for doctors treating cancer patients or for end-of-life care.
The guidelines sparked controversy when a draft was released in the fall. Some pain specialists and patient advocates cited a lack of evidence supporting many of the recommendations. Critics voiced concern that the guidelines could result in patients being denied pain relief they legitimately need.
NPR’s Robert Siegel spoke with Dr. Debra Houry, director of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control, who’s been involved in the development of the guidelines from the beginning.
Here are interview highlights, edited for length and clarity.
On how Houry hopes the guidelines will change the way doctors treat pain
I hope this will allow primary care providers to have a conversation with patients about the risks and benefits of opioids and to consider non-opioids as the first-line treatment for pain.
The doctor can tell you that up to 1 in 4 patients with chronic pain can experience opioid dependence. A family history of addiction, mental health issues and other chronic issues can put you at higher risk.
On the potential pushback from people in chronic pain
What I would say is, let’s try some other options first. Let’s try a high dose of a nonsteroidal [anti-inflammatory drug], let’s try an SSRI-type medication, let’s try some of these other medications first and maximize them. We absolutely want to treat your pain, but we want to do it safely. And opioids may be warranted. … If opioids are warranted though, we’re not saying to use them in isolation. They should be used in combination with things like exercise therapy or nonsteroidal medication.
Critics, including the American Academy of Family Physicians, faulted the CDC’s initial recommendation that opioids should not be first-line therapy for chronic pain, saying that’s too strong a stance given the weakness of the evidence.
Well, I think there is weakness [in evidence] on the benefits of opioids but there’s been significant progress on the risk of opioids. We see that there is an increased risk of car crashes, death from overdose. And that’s why we have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted. On the other end, non-opioids, there is evidence for their benefits.
There is room for more science as we continue to revise and update the guidelines, but given the number of Americans dying each day from opioid overdoses — 40 a day — we have enough evidence today about the risks. That being said, I can tell you as a practicing physician that many guidelines I use are often based on low-quality events, and that doesn’t mean bad evidence. That just means there are not a lot of randomized controlled trials.
On criticism of the initial recommendation to limit prescriptions for acute pain to three days
So we heard that feedback, and for that specific recommendation there is now a range of up to seven days. We want to make sure patients have appropriate access, but we also want to limit the number of patients who become addicted, Having too many days of medication can put you at risk for addiction, so we do think it is important to give the shortest course possible.
Response to the concern over the low starting dose recommended
We’ve actually put a range in there. At 50 morphine milligram equivalents [a standardized measure of potency], we say that you should assess the risks and benefits. And at 90 you should really think hard … consider referring them to a pain specialist. This is for initiation of opioids. We do not think that an opioid-naive patient — someone who hasn’t been on opioids before — should be started on a high dose of opioids. We have seen that the higher the doses of opioids, the more likely you are to overdose. So we believe in starting low and going slow.
What should doctors tell people who suffer chronic pain and are on opioid therapy now?
It would include having that conversation about the risks and benefits. With the newer evidence we know about the risks, I believe every patient should be aware of the risks and benefits of their treatment. And I do think physicians should routinely monitor their patients and reassess them. If a patient is doing fine on a low dose, we’re not saying to change that care. But if a patient is not improving in function or is having adverse events, I think they should reconsider what medication they’re on.