The Centers for Disease Control updated its guidelines for prescribing opioids to treat pain, replacing 2016 measures and coming at a time where opioid overdoses still remain prevalent.
“We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,” said Dr. Christopher M. Jones of the CDC’s National Center for Injury Prevention and Control.
Local doctors said the new guidelines shift away from stringent rules around prescribing that had unintended consequences for patients trying to manage chronic pain. The expanded guideline aims to ensure equitable access to effective, informed, individualized, and safe pain care, the CDC said.
“The science on pain care has advanced over the past six years,” said Dr. Debbie Dowell, chief clinical research officer for CDC’s Division of Overdose Prevention. “During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians. 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.”
Previous guidelines saw ‘severe psychological consequences’
The 2016 guidelines were controversial at times, with the CDC having to release instructions in 2019 for providers not to misapply the guidance, such as through the sudden discontinuations of opioids.
Dr. Priyesh Mehta, interventional pain physician at the Dayton Outpatient Center, said there has been an initiative to prescribe less opiates, but the 2016 guidelines hurt patients dealing with pain by cutting patients off of pain killers and left chronic pain unmanaged.
“There is a general push to prescribe less opiates as a provider over the past couple years. With the recent update, however, it does clarify specific criteria in the 2016 CDC opiate guidelines that providers looked to as a hard and fast requirement to their prescribing habits,” Mehta said. “The 2016 guideline unfortunately led to immediate and fast tapering of opiates that may have been working well for patients and in turn resulted in severe psychological consequences, as well as chronic pain left unmanaged and patients isolated.”
Doctors saw more patients in area emergency departments following the outcomes of those 2016 guidelines. Dr. Nancy Pook, medical director of the operation command center with Kettering Health emergency physicians, said, following the 2016 guidelines being released, they saw a large number of patients in the emergency room who had been cut off from pain medication.
Treating patients’ pain by individual cases
The 2022 guidelines offer 12 recommendations addressing the following areas: determining whether to initiate opioids for pain, selecting opioids and determining opioid dosages, deciding duration of initial opioid prescription and conducting follow-up, and assessing risk and addressing potential harms of opioid use.
Doctors are hopeful these new guidelines will help providers take each patient’s individual case into consideration, such as if patients need to be on pain medication longer or need more follow-up care.
“In general, providers should take into account every patient’s unique scenario and prescribe accordingly. The new update will hopefully provide more clarity on when it is appropriate for patients to initiate opiates to help ease any provider’s concerns about prescribing,” Mehta said.
These new guidelines include more recommendations on tapering off pain medication and loosened restrictions on opioid prescriptions.
“It takes into account the circumstances where that may not be as feasible,” Pook said.
Additional methods for addressing pain
With the exceptions of sickle cell disease, cancer, and palliative care, there are also non-pharmaceutical treatment options for pain, such as massage and physical therapy. Doctors like Mehta use a multidisciplinary model to treat pain, including exercise, medications, injections, and behavior therapies.
“Those that participate in this model of care do very well in treating their chronic pain with or without medications,” Mehta said.
With the variety of pain treatments, along with more knowledge of opioids and pain killers, these create safer prescribing environments. Doctors also have a better understanding of how opioids interact with other drugs.
“We know more and more about which medications are safer to prescribe together,” Pook said. “I think that these guidelines do a good job of outlining many of those things we consider every single day for every patient when they’re dealing with pain.”
Dr. Kimberly Wascak, who specializes in emergency medicine and is an associate medical director at Miami Valley Hospital, said Premier Health has adopted these standards. Emergency doctors work on a case-by-case basis to determine if opioids should be prescribed for a patient, as well as implementing the lowest dose possible for the shortest amount of time while also having a plan for a follow-up.
“Over that last five years, we’ve seen a decrease in the number of prescriptions written by our providers,” Wascak said. Due to increased awareness, patients have more understanding to the risks of addiction with opioids. Doctors have also found anti-inflammatory medication or acetaminophen are just as effective, Wascak said.
Doctors continue to screen for addiction, opioid risks
Area doctors are still watching out for patients with opioid use disorders amid the relaxing of these guidelines. Drug overdose deaths have continued to rise following the COVID-19 pandemic, with deaths exceeding 100,000 in the 12-month period ending June 2022, according to the CDC. The specificity of the drugs was not entirely available, but previous CDC data showed 74.8% of drug overdoses were related to opioids. The CDC, at the time of releasing these new guidelines, also said the current state of the overdose crisis is being driven by illicit synthetic opioids like illicitly made fentanyl and also resurgent methamphetamine.
Wascak, who is also the physician lead for an Ohio Department of Health grant focused on treating opioid use disorder, said doctors have also been keeping opioid use disorder in mind when treating patients’ pain, such as providing Narcan or naloxone to patients if doctors think they may be at risk of overdosing, whether it is on their mediation or illicit drugs.
“We’re also giving out Narcan kits for patients at risk for opiate overdose,” Wascak said. Substance use navigators in local emergency departments have also become more prevalent and available, connecting patients with treatment options and referrals.
Screening for, knowing the signs of opioid use disorder
Emergency room doctors have also implemented universal screening to see if those patients have opioid use disorders or at risk of developing one, along with making sure patients are informed about the risks associated with opioids.
“With any patient who is going to be prescribed an opioid, a risk analysis should be made that includes a family history of substance use disorder,” Dr. Leslie Dye, assistant medical director at OneFifteen, said. “In addition, rather than waiting for someone to develop the signs and symptoms of the disease, the patient should be aware of the basic principles of the disease and know ahead of time what symptoms can be warning signs of a problem.”
When a patient has been prescribed any opioid medication, Dye said they should watch for these signs:
- Taking the medication earlier than prescribed or taking more pills than prescribed
- Craving the pills as soon as they begin to wear off
- Continuing to take the pills even when you are not having pain because you like the effect
- Taking the pills to escape emotions like anger or sadness
“It’s also important for a patient to know that if these signs do occur, it is not because they did anything wrong,” Dye said. “It may just be because their brain works differently, and it is important for them to recognize this and contact their clinician immediately.”
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