In long-awaited final guidelines for prescribing opioid medications, federal health officials mostly kept recommendations widely criticized as restricting access to pain-relieving drugs.
And so the effort to change the prescribing practices of primary-care physicians, who write nearly half of all opioid prescriptions, may not have the influence many are hoping it will.
“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 welcomed the CDC's voluntary guidelines, 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 epidemic of controlled substance abuse and the resurgence in heroin use.
The CDC recommends doctors prescribe over-the-counter pain medications, exercise and behavioral treatments before using opioids. When opioids are prescribed, the CDC suggests low-dose versions of immediate-release pain relievers, rather than prescribing long-acting, extended-release opioids.
CDC Director Dr. Tom Frieden said the guidelines should offer doctors safe treatment options for patients with chronic pain, who make up only 5% of long-term opioid users but account for 70% of all pain-relief prescriptions.
“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 pain, such as cancer or end-of-life care.
But in the 1990s, some specialists argued that doctors were under-treating common forms of pain that could be relieved by opioids, such as backaches and joint pain. The message was amplified by multimillion-dollar promotional campaigns for new, long-acting drugs including OxyContin, which was promoted as less addictive.
According to the CDC, 249 million opioid pain medication prescriptions were written in 2013. The 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. Overdoses killed more than 46,000 people in 2013, claiming more lives that year than car crashes.
Time constraints present a hurdle to changing course. It's much easier for a busy clinician to prescribe a 30-day supply of oxycodone or Percocet for chronic pain than it is to persuade a patient to try physical therapy.
The guidelines also recommend that clinicians review data in state prescription drug-monitoring programs before prescribing opioid therapy, and check the data periodically to ensure a patient is not risking overdose.
Providers have argued that mandating a review of databases imposes an unreasonable administrative burden and could lead to inaccurate information.
Dr. Gail D'Onofrio, chair of Yale School of Medicine's emergency medicine department, said improving doctors' opioid prescribing practices must involve education and resources 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 up together, and looks at these patients, and sees what would be the best options for them.”
