In a whitepaper titled “Principles for Patient-Centered Opioid Prescription Guidelines,”* the Alliance for the Treatment of Intractable Pain argues that the CDC Guidelines for Prescribing Opioids for Chronic Pain “must be withdrawn and rewritten” to recognize both the indispensable role that opioids play in chronic pain management, and the central role of physicians in assessing and prescribing medications as patients require.
Below is a brief excerpt, offering patient-focused recommendations for the CDC, with additional commentary provided by alliance representatives Richard A. Lawhern, PhD, and Steven E. Nadeau. Dr. Lawhern is a technically trained non-physician with 20 years of experience in peer-to-peer patient support groups for chronic pain patients. Dr. Nadeau serves as Associate Chief of Staff for Research at the Malcom Randall VA Medical Center, and Professor of Neurology and Clinical and Health Psychology at University of Florida College of Medicine.
1. Doctors must be free to prescribe both opioid and non-opioid analgesics for durations and in doses that they deem adequate for the patient to sleep and to function in daily life while acute conditions are resolving. Primary effects in pain reduction must be balanced against negative side effects or hazards in the individual patient.... Detailed standards for prescribing are most appropriately developed by medical professional societies and specialized certification boards familiar with conditions of medical practice, rather than by legislation or regulation by state regulatory authorities.
2. The incidence of chronic opioid prescribing in nonsurgical populations is on the order of 0.136% with “chronic” defined as 10 or more opioid prescriptions per year or continuous prescribing for 120 days or more. When records of surgical patients were analyzed after 11 common surgical procedures, ... incidence of chronic prescribing ... remained unchanged in four of these procedures. In the remaining procedures, chronic prescribing was observed in a maximum of 0.7% of post-surgical patients. Current literature does not support time or dose limits on post-surgical opioid prescribing for patients who are properly screened prior to the procedure and monitored thereafter. Patients must be evaluated and treated for post-surgical pain as individuals, informed by guidance on best practices.
3. There is widespread concern that unmanaged or casual availability of opioids may lead individuals to become addicted. While an increased availability of prescription opioids before 2010 might have contributed to their diversion to recreational use, the literature suggests that risk of addiction in patients with no previous history of opioid use is very small – less than 1% in fact.... Incidence of opioid abuse among patients who are prescribed opioids after surgery is less than 0.6%. Incidence of opioid abuse in post-surgical patients prescribed opioids is, therefore, too low and too subject to confounds to measure reliably. There is a need to better train general practitioners to recognize and distinguish between indications of problematic opioid use versus emergence of chronic pain due to failed surgery.
4. There is no evidence that the restriction of opioid medications for patients reduces overdose deaths. To the contrary, it is clear that reformulation of OxyContin in 2010 to reduce its abuse potential was accompanied by a sustained increase in overdose deaths involving heroin and other street drugs. There is also research to demonstrate that the restriction of prescription opioids since that time period may actually be contributing to the opioid crisis by driving patients in desperate pain toward illicit drugs for relief. The US Drug Enforcement Administration has recommended further reduction of production quotas for scheduled drugs found to be “subject to diversion.” However, prescribing levels are presently at a 10-year low and hospitals across the country are experiencing shortages of opioid analgesics needed in surgery. The DEA should end these restrictions.
5. The significance of “relative risk” of untoward outcomes versus opioid dose level should be evaluated in the context of absolute risk. Studies used by the CDC to write the guidelines show an increased risk of apparent overdose death associated with higher dosing. However, overall risk of overdose death across all dose levels was on the order of 0.05% or lower. For doses greater than 100 MMED, the absolute annual risk of dying was estimated at 0.21% to 0.25% per year. In a related study … the annual risk of overdose death with a MMED of greater than 400 was 0.5%.
*An early version of this paper was published in April 2017 by National Pain Report and The Journal of Medicine of the US National College of Physicians, and featured by Pain Week under the title “What if Prescribing Guidelines Were Patient Centered?” The opinions presented herein do not represent those of the VA, federal government, or authors' affiliated organizations.