In long-awaited final guidelines for prescribing opioid pain medications, federal health officials mostly kept in place recommendations that were criticized by some as restricting access to pain relieving drugs.
And so the effort to change opioid prescribing practices among primary-care physicians, who prescribe nearly half of all opioid prescriptions, is likely to face challenges.
“Unfortunately, I'm not sure that the people who are prescribing these medications long-term are going to heed the pretty practical advice that's provided by the Centers for Disease Control and Prevention,” said Dr. Una McCann, professor of psychiatry at Johns Hopkins Medicine.
Addiction medicine experts Tuesday welcomed the CDC's recommendations, which zeroed in on the importance of avoiding opioid prescriptions as the first line of treatment for patients with chronic pain. Prescription opioids have driven the current controlled substance abuse epidemic, as well as the recent resurgence in heroin use.
The CDC recommends that doctors prescribe over-the-counter pain medications, exercise and behavioral treatments before using opioids. When opioids are prescribed, the CDC suggests beginning with low-dose versions of immediate-release pain relievers rather than prescribing the long-acting, extended-release opioids. That reduces the chance of misuse or abuse of those drugs.
CDC Director Dr. Tom Frieden said the guidelines should offer physicians safe treatment options for patients with chronic pain, who make up only 5% of long-term users of opioids but account for 70% of all prescriptions for pain relievers.
"Changing medical practice isn't quick, and it isn't easy," Frieden said. "But we think the pendulum on pain management swung way too far toward the ready use of opioids."
And in fact, the guidelines are a return to an older practice of medicine.
Physicians trained in the 1960s and 1970s—amid a wave of urban heroin use—were taught to reserve opioids for the most severe forms of pain, such as cancer or end-of-life care. That approach remains accepted.
But in the 1990s, some specialists argued that doctors were undertreating common forms of pain that could benefit from opioids, such as backaches and joint pain. The message was amplified by multimillion-dollar promotional campaigns for new, long-acting drugs like OxyContin, which was promoted as less addictive.
One current hurdle to curbing the number of prescriptions is that it's much easier for a busy clinician to prescribe a 30-day supply of oxycodone or Percocet to treat a patient's chronic pain than it is to convince him or her to do physical therapy. The time constraints affecting physicians' practice has never been more acutely felt than in this era of healthcare reform that emphasizes quality and value-based payment.
According to the CDC, 249 million prescriptions were written for opioid pain medications by healthcare providers in 2013. Such wide availability of opioids since the 1990s has led to a drug abuse epidemic that has affected almost every part of the U.S.
The number of drug overdose deaths increased by 242% between 1999 and 2014, according to the National Institutes of Health. Drug overdoses killed more than 46,000 people in 2013, killing more that year than car crashes.
The CDC guidelines also recommend clinicians review data through state prescription drug monitoring programs before starting a patient on opioid therapy and check it periodically while they are being treated to determine if a patient is receiving doses that could put them at risk for overdose.
Providers have been critical of prescription drug monitoring programs. They say mandating a review of state-run drug prescription databases could lead to inaccurate information and would be an administrative burden for them. They also have said frequent prescription changes might reveal a lack of coordination among providers, not drug abuse.
According to Dr. Gail D'Onofrio, chair of Yale School of Medicine's emergency medicine department, improving opioid prescribing practices of primary-care physicians must involve education and the resources needed to find evidence-based pain care alternatives.
“I can't just say to a patient, 'Go and get some acupuncture,' ” D'Onofrio said. “We really need to have more of an integrated service between primary care and pain management that lines together and looks at these patients and sees what would be the best options for them.”