In an attempt to combat the nation's deadly prescription painkiller epidemic, the Centers for Disease Control and Prevention on Tuesday issued its first set of guidelines on dispensing the addictive medications, urging doctors to avoid providing them for chronic pain.
The agency said the risks from prescribing opiates, a class of morphine-like painkillers, far outweigh the benefits for most patients with long-term pain, except for those receiving cancer treatment or end-of-life care. When the drugs are necessary, the CDC advises doctors prescribe the lowest possible dose for the shortest amount of time.
About 40 Americans die each day from overdosing on prescription painkillers, according to the CDC. In 2013, an estimated 1.9 million people abused or were dependent on prescription opiates.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," said CDC director Thomas Frieden. "We hope to see fewer deaths from opiates. That's the bottom line. These are really dangerous medications that carry the risk of addiction and death."
The guidelines are intended for primary care physicians, who prescribe nearly half of opiates, including drugs such as Vicodin and OxyContin. Doctors aren't legally obligated to follow the recommendations, which are intended for adult patients.
The CDC hopes the guidelines will help doctors determine when to begin or continue opiates for chronic pain, which type of painkiller to choose, how long to administer the drugs and how to weigh their risks.
The recommendations are "a game changer" that doctors are likely to follow, said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing.
"For the first time, the federal government is communicating clearly that the widespread practice of treating common pain conditions with long-term opioids is inappropriate," Kolodny said. "The CDC is making it perfectly clear that medical practice needs to change because we’re harming pain patients and fueling a public health crisis."
Most prescription opiates on the market are as addictive as heroin, and poorly control chronic pain, Frieden said. Doctors should use therapies other than opiates first, including exercise or non-steroidal anti-inflammatories, such as aspirin or ibuprofen, he said.
When the benefits of prescription opiates outweigh the risks, doctors should talk to patients about their treatment goals and when they will stop using the drugs. Due to a high risk of overdose, physicians should avoid prescribing opiates at the same time as benzodiazepines, such as anti-anxiety drugs Valium and Xanax.
Patients with acute pain, such as that caused by an injury, usually need prescription opiates for only three days. Prescribing the drugs for more than seven days is rarely needed, he said. "When opiates are used, start low and go slow," Frieden said, meaning doctors should increase the dose of medication slowly and only when necessary. Doctors should check every three months to see if the benefits of opiates still outweigh the risks, according to the guidelines.
Telling patients and doctors that opiates are rarely needed for more than a few days "will help prevent patients from getting addicted and help keep highly addictive drugs from accumulating in medicine chests," Kolodny said.
If patients abuse opiates, doctors should help them get treatment supported by strong medical evidence, such as the therapies buprenorphine or methadone, which block the effects of opiates.
The CDC's hard line on opiates is a major shift from conventional wisdom about relieving pain.
Although there has never been much evidence that opiates ease chronic pain, doctors were told for decades to consider pain as a "vital sign" that needed to be addressed, wrote addiction medicine specialist Yngvild Olsen, medical director of Reach Health Services in Baltimore, in an editorial in JAMA.
That advice to manage patients' pain was accompanied by "misleading marketing of prescription opioids by manufacturers, who minimized the risks of misuse and addiction," Olsen wrote. The pressure to manage pain led doctors to "miss or dismiss the presence of addiction in their patients," she added.
Patients should ask questions if their doctors want to prescribe opiates, said Deborah Dowell, senior medical adviser in the division of unintentional injury prevention at the CDC’s National Center for Injury Prevention and Control. Key questions to ask include: Is an opiate necessary? What are the risks? What are the benefits? How long should I take this? Are there alternatives? What we hope to accomplish by using an opiate? How will you know when we've met our goal?
Sen. Edward Markey, D-Mass. praised the CDC for releasing the guidance.
“Just as we need rules of the road to prevent injury and death, we need strong guidelines that can help prevent abuse of and addiction to opioid painkillers,” Markey said in a statement.
“While these are important measures we need prescribers to take, they are just guidelines and we need requirements to ensure all prescribers of opioid painkillers are educated in safe prescribing practices and the identification of possible substance use disorders," Markey said. "I will continue to work with my congressional colleagues to pass legislation that ensures all prescribers of opioid pain medication get the education needed to help prevent addiction before it takes any more lives of our friends, families and loved ones.”
This Feb. 19, 2013 file photo shows OxyContin pills arranged for a photo at a pharmacy in Montpelier, Vt.
