The CDC (Centers for Disease Control) has finalized their guidelines/recommendations with regards to prescribing opioid medications in chronic pain by primary care physicians. The recommendations are in response to an increase in both the prescribing of opioid pain medications by primary care physicians and in response to an increase in overdoses related to prescription narcotics. Between 1999 and 2014, over 165,000 Americans died as a result of overdose of opioid pain medications, with the rate increasing over the past several years.
“Opioid pain medications are not effective in treating chronic pain.“
Although the guidelines are not legally binding on physicians, they are likely to have a profound impact on how chronic pain is treated. Physicians, already skittish to prescribe narcotics are likely to be even more hesitant to prescribe moving forward. The recommendations can be summarized fairly succinctly.
- “In summary, evidence on long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determine long-term benefits versus no opioid therapy, though evidence suggests risk for serious harms that appears to be dose-dependent. “
- Opioids should not be considered a first line therapy for treatment of chronic pain, with the exception of cancer and end of life care.
- “Several nonpharmacologic and nonopioid pharmacologic treatments have been shown to be effective in managing chronic pain in studies ranging in duration from 2 weeks to 6 months.” Among the recommendations prior to considering use of chronic pain medications including Cognitive Behavioral Therapy, Exercise, and Physical Therapy.
- Extended or Long Acting Formulations of opioids should be avoided.
- The doses of opioids prescribed should start at a level at or below the equivalent of 50mg of Morphine per day and not exceed 90mg of Morphine per day.
- Tapering of dose should begin as soon as possible.
- “If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”
The guidelines support the evidence that long term use of opioid pain medications are not effective in treating chronic pain. However, many physicians have expressed concern that access to appropriate care will be limited for those patients who do require chronic pain medications. Also, although many physicians agree that the alternatives to opioids are preferred, insurance does not always adequately reimburse for the alternatives.
Even though the guidelines are not law, most believe that medical boards and insurance companies will use the guidelines to further monitor physician behaviors. In my discussions with several physicians, they have express increased concern regarding prescribing opioids moving forward. The need for alternatives to opioid medications will continue to grow and patients and physicians will need to better understand the myriad of options available to them.
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