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9 Articles in Volume 16, Issue #3
CDC Issues Final Guidelines for Opioid Prescribing: PPM Editorial Board Responds
Don L. Goldenberg, MD, FACP
Don't Flinch From Prescribing Pain Medications!
Help Patients Achieve Diet/Weight Goals to Manage Pain
Hormone Testing and Replacement: Status Report 2016
Living With, and Managing, Chronic Pain: A Patient’s Story
Nerve Decompression Surgery Can Reverse Neuropathy of the Foot
Pulsed Electromagnetic Field Therapy: Innovative Treatment for Diabetic Neuropathy
Specialized Pharmacies Step Into Risk-Management Role

CDC Issues Final Guidelines for Opioid Prescribing: PPM Editorial Board Responds

The recommendations are for non-cancer chronic pain patients, and are aimed at reducing the opioid epidemic of misuse, abuse, and overdose.
Page 5 of 6

Patients know the words narcotic/opioids. And a small group of pain patients are so fearful of “getting addicted” that they object to using an opioid even once. There seems to be a total lack of recall about the long and successful record of treating both chronic non-cancer and cancer patients who took their pain medications with reasonable outcomes and without “a problem.”

It appears foolish to look only at the lack of evidence-based medicine studies of long-term opioid use, when the vast majority of pain specialists have had no problem working with them and giving patients what they needed to return to being healthy, functioning individuals.

Examine the Literature

Today, more women are surviving breast cancer. But the chemotherapy required to halt the cancer often induces a painful peripheral neuropathy. Although the cancer is gone, they are left with pain. There are over 180,000 women in the UK and even more in the US who have great difficulty obtaining pain medications for their peripheral neuropathy because their lives are no longer at risk from cancer. Their oncologist is finished and has provided a fine outcome. They are alive but in pain. Will their PCPs be comfortable prescribing “pain meds” for that?

I am saddened to see more excuses for physicians to “just say no” to opioids. Some patients may need opioids in larger doses than the “Guidelines” say since the “Guidelines” can’t prevent the development of receptor site tolerance (which does NOT mean addiction to those who chatter on about it). Nor do the Guidelines accommodate a patient taking opioids for years and who may—perioperatively and post-operatively (as outpatients)—need more opioid medication than the “Guidelines” may, uh, suggest. Also, consider the patient with a premorbid pain history using polymodal/multimodal opioid pain treatment and who presents for a related or unrelated surgical procedure requiring analgesics.

I left the full-time practice of pain medicine to provide insight, knowledge, and a modicum of wisdom to pharma over a decade ago, although I still practice and consult. Lots of docs, even a neurologist/pain specialist like me, even those I considered friends, were livid with me, saying I had “gone to the dark side.”

The CDC Guidelines were published on line two days before I wrote this. Care to guess how many of the physicians who chided me have contacted me in the last 48 hours for advice about joining pharma?? At last count, the number was in the double digits.

Ultimately, it is the patients who are victimized and may rightly be horrified. Upon further reflection, the “Guidelines” may undergo some modification. In the meantime, prescribers of opioids may be interested in a complete opioid reference/review articles and information on opioids and other nonopioid analgesic medications.6,26

We’ve been here before—in the name of “medical” and possibly “political” correctness—trying to fix the real problem of opioid over-dosage and death by causing more problems.

My Opinion: Information Somewhat Biased and Incomplete

By Leonard B. Goldstein, DDS, PhD

While there must be some consensus with the statements in the CDC Guidelines, I believe that the information was somewhat biased and incomplete. All of us in the field of “Pain Management” agree that opioids are over-prescribed in many instances. However, there can be no denial of the efficacy in the use of opioid analgesics, when used properly, and monitored, even for chronic non-cancer pain.

I can also agree with some of the points in the JAMA Editorial made by Yngvild Olsen, MD, MPH, suggesting that “…Education about substance use disorders and chronic pain management should start in medical school (and dental school, etc.) and continue through residency training in all patient-care specialties…”27

However, I believe that the CDC recommendations failed to include the integrative and complementary methods available for the treatment of most chronic pain conditions, including, but not limited to:

  • Osteopathic Manipulative Treatment (OMT)
  • Physical therapy and therapy modalities
  • Acupuncture
  • TENS, ultrasound, electro-Galvanic stimulation, etc.
  • Transcranial electrical stimulation
  • Progressive relaxation and biofeedback training (including meditation and yoga)
  • Behavioral modification and psychosocial interventions

In many cases, these therapies will result in similar outcomes to the use of opioid medication, with greater patient acceptance and lower costs.28-30

I hope that as we move forward, we will understand the benefits of the judicious use of prescription opioids for “acute” pain, using the best dosage for the needed time period; but also look to other methods either alone or in conjunction with low dose opioids for chronic, non-cancer pain (outside of palliative care or end-of-life treatments).

Welcome News for Pain Specialists

By Elmer Pinzon, MD, MPH

Due to the recent CDC Guidelines on opioid pain management, the pain management community has begun adapting to these non-binding guidelines.

For those of us who have always looked to other sources of providing pain-relief (eg, complementary alternative medicine, physical therapy, non-opioid management, exercise, etc.), the CDC Guidelines are welcome news and seem to encourage the pursuit of nonopioid treatment options. Here, a look at the CDC’s position and reaction from notable medical groups.

The summary of the CDC comments included the agency’s Director Tom Frieden, MD, MPH, who said in a recent news teleconference: “The science of opioids for chronic pain is clear. For the vast majority of patients, the known, serious and all too often fatal risks far outweigh the unproven and transient benefits, and there are safer alternatives.”

Accordingly, the first of the agency’s 12 recommendations states that opioids should not be the first-line therapy for chronic pain, and that clinicians should consider nonopioid pain relievers or non-pharmacological options like exercise and cognitive behavioral therapy before opioids.

Other recommendations include:

  • Conducting a urine test before opioid therapy
  • Starting at the lowest dose possible and avoiding doses of 90 morphine milligram equivalents (MME) or more
  • Prescribing immediate-release as opposed to longer-acting opioids
  • Limiting treatment for acute pain to usually no more than 7 days

These non-binding guidelines do not apply to patients who are receiving palliative care or end-of-life care, or treatment for active cancer. The CDC tailored the recommendations for primary care clinicians (PCP), who account for roughly half of opioid prescriptions.

In Dr. Frieden’s view, clinicians play a key part in reducing the rate of addiction and death associated with these drugs. “The prescription overdose epidemic is doctor-driven. It can be reversed in part by doctors’ actions.”

Research Not Robust

Last updated on: April 18, 2018
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