The Opioid Controversy

Reaction to CDC prescribing guidelines: a good first step?

As states combat a raging opioid epidemic, the Centers for Disease Control recently came out with its revised clinical guidelines aimed at slowing a public health crisis. Though voluntary, experts believe they’ll have a ripple impact nationally. The guidelines are meant for primary care physicians who treat adults for chronic pain in outpatient settings. Among the 12 recommendations: practitioners should opt for shorter-acting, lower dosages, and limit opioid use to acute pain episodes. Opioids should not be a first-line therapy outside of major surgery. Cancer, palliative and end-of-life care are exempt, however. CDC also recommends that doctors conduct urine drug tests before prescribing.

The reaction from medical organizations reflects the complexity of the problem. While praising efforts to curb opioid abuse, many raise concerns. The American Medical Association, for instance, points to scant scientific evidence supporting strict limits on dosage and duration. Conflicts with state laws, gaps in reimbursement and insurance coverage for alternative treatments all create hurdles to the guidelines’ successful implementation, the AMA said.

Physicians also report feeling under intense pressure to treat pain. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey encourages overly aggressive prescribing of opioids because survey data is used to rate providers and set reimbursement.

While the guidelines do not address physician education, greater knowledge of pain management, including effective alternatives to opioids, must be part of any comprehensive solution, the AMA said.

Pendulum Swings Back

The guidelines are meant to be a “flexible tool” that can be adjusted as needed, the CDC said. But some groups caution about unintended consequences. “The CDC imprimatur makes it more likely that these guidelines become de facto requirements through adoption by state health departments, professional licensing bodies, or insurers,” the American Cancer Society stated in response. Facing regulatory risks, few primary care physicians might want to prescribe opioids. Yet many see that as a positive step.

In 2014 alone, opioids contributed to 28,648 deaths, a record year, with 18,893 lethal overdoses related to prescription pain relievers, and 10,574 deaths related to heroin. Primary care clinicians wrote nearly half of all dispensed opioid prescriptions, and the growth in prescribing rates among these clinicians has been above average, according to the CDC. Put more dramatically, in 2012 health care providers wrote 259 million prescriptions for opioid pain relievers, enough for every American adult to have a bottle of pills.

The guidelines, while not meeting rigorous standards of evidence, would begin to turn the tide, saving lives by reducing the flow of opioids. Hailing the guidelines, the group Physicians for Responsible Opioid Prescribing said this is the “first time the federal government is communicating clearly to the medical community that long-term use of opioids for common conditions is inappropriate.” Until more data becomes available, the recommendations serve to reinforce existing medical principles of drug prescribing.

More Federal Efforts

Coinciding with the CDC guidelines, the Obama administration plans to invest over $1 billion on improving access to medications like buprenorphine. A bill in Congress—the Recovery Enhancement for Addiction Treatment Act, or TREAT, would raise the current cap on the number of patients prescribers of buprenorphine can see.

But without more physicians stepping up to prescribe the drug, greater access could prove difficult. Only 32,000 doctors nationwide have taken the eight-hour course and applied for the special license they need to prescribe buprenorphine. Patients are not clamoring for such treatment either. Addiction recovery groups say the real problem is lack of insurance coverage.

Fewer than half of the 2.2 million people who need treatment for opioid addiction get it, the Department of Health and Human Services estimates. The agency recently announced an evidence-based HHS-wide initiative that targets three top areas. HHS wants to expand access to medication-assisted treatment for opioid use disorder, increase the use of naloxone, and inform opioid prescribing practices.

National Pain Strategy

The Institute of Medicine has called chronic pain a “significant public health problem” in the U.S. In 2011, the organization cited the need for a “cultural transformation in the approach to pain.” The IOM said physicians need more education, starting in medical school, about pain care.

Spurred on by these recommendations, the National Institutes of Health came out recently with a National Pain Strategy. The plan moves away from an opioid-centric treatment paradigm. Along with increased provider and patient education, the strategy calls for more realistic expectations for pain relief.