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CDC Has Advice For Primary Care Doctors About Opioids

Mar 15, 2016
Originally published on March 17, 2016 11:25 am

In response to the opioid epidemic that has swept the country, the Centers for Disease Control and Prevention released long-anticipated guidelines on prescribing opioid painkillers such as OxyContin and Percocet.

They were published Tuesday in JAMA, the Journal of the American Medical Association.

The advice is aimed at primary care physicians, who prescribe nearly half of the opioid painkillers consumed in the U.S. The guidelines aren't intended for doctors treating cancer patients or for end-of-life care.

The guidelines sparked controversy when a draft was released in the fall. Some pain specialists and patient advocates cited a lack of evidence supporting many of the recommendations. Critics voiced concern that the guidelines could result in patients being denied pain relief they legitimately need.

NPR's Robert Siegel spoke with Dr. Debra Houry, director of the Centers for Disease Control and Prevention's National Center for Injury Prevention and Control, who's been involved in the development of the guidelines from the beginning.

Here are interview highlights, edited for length and clarity.

On how Houry hopes the guidelines will change the way doctors treat pain

I hope this will allow primary care providers to have a conversation with patients about the risks and benefits of opioids and to consider non-opioids as the first-line treatment for pain.

The doctor can tell you that up to 1 in 4 patients with chronic pain can experience opioid dependence. A family history of addiction, mental health issues and other chronic issues can put you at higher risk.

On the potential pushback from people in chronic pain

What I would say is, let's try some other options first. Let's try a high dose of a nonsteroidal [anti-inflammatory drug], let's try an SSRI-type medication, let's try some of these other medications first and maximize them. We absolutely want to treat your pain, but we want to do it safely. And opioids may be warranted. ... If opioids are warranted though, we're not saying to use them in isolation. They should be used in combination with things like exercise therapy or nonsteroidal medication.

Critics, including the American Academy of Family Physicians, faulted the CDC's initial recommendation that opioids should not be first-line therapy for chronic pain, saying that's too strong a stance given the weakness of the evidence.

Well, I think there is weakness [in evidence] on the benefits of opioids but there's been significant progress on the risk of opioids. We see that there is an increased risk of car crashes, death from overdose. And that's why we have decided that because of that, and the uncertain benefits of opioids, that continuing to prescribe them for chronic pain is not warranted. On the other end, non-opioids, there is evidence for their benefits.

There is room for more science as we continue to revise and update the guidelines, but given the number of Americans dying each day from opioid overdoses — 40 a day — we have enough evidence today about the risks. That being said, I can tell you as a practicing physician that many guidelines I use are often based on low-quality events, and that doesn't mean bad evidence. That just means there are not a lot of randomized controlled trials.

On criticism of the initial recommendation to limit prescriptions for acute pain to three days

So we heard that feedback, and for that specific recommendation there is now a range of up to seven days. We want to make sure patients have appropriate access, but we also want to limit the number of patients who become addicted, Having too many days of medication can put you at risk for addiction, so we do think it is important to give the shortest course possible.

Response to the concern over the low starting dose recommended

We've actually put a range in there. At 50 morphine milligram equivalents [a standardized measure of potency], we say that you should assess the risks and benefits. And at 90 you should really think hard ... consider referring them to a pain specialist. This is for initiation of opioids. We do not think that an opioid-naive patient — someone who hasn't been on opioids before — should be started on a high dose of opioids. We have seen that the higher the doses of opioids, the more likely you are to overdose. So we believe in starting low and going slow.

What should doctors tell people who suffer chronic pain and are on opioid therapy now?

It would include having that conversation about the risks and benefits. With the newer evidence we know about the risks, I believe every patient should be aware of the risks and benefits of their treatment. And I do think physicians should routinely monitor their patients and reassess them. If a patient is doing fine on a low dose, we're not saying to change that care. But if a patient is not improving in function or is having adverse events, I think they should reconsider what medication they're on.

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ROBERT SIEGEL, HOST:

In response to the opioid epidemic that swept the country, the Centers for Disease Control and Prevention today released its long-anticipated guidelines on prescribing opioids, drugs like OxyContin or Percocet. When a draft of the guidelines was released last fall, it drew some criticism from pain specialist and patient advocates. They said some patients could be denied the relief they legitimately need.

The guidelines are not meant for cancer patients or for end-of-life care. They're aimed at primary care physicians who prescribe nearly half of the opioid painkillers consumed in the U.S. Debra Houry is the director of the CDC's National Center for Injury Prevention and Control. She's been involved in the development of these guidelines from the beginning, and she joins us now. Welcome.

DEBRA HOURY: Thank you.

SIEGEL: How do you hope these guidelines will change how primary care physicians treat pain?

HOURY: Well, I hope that this will really allow primary care providers to have a conversation with patients about the risks and benefits of opioids and to really considered non-opioids as the first-line treatment for pain.

SIEGEL: If I were having a conversation with my family doctor about the risks of my using opioids for some terrible pain I have in my back, what should actually be sad in that conversation? What does my doc tell me?

HOURY: The doc can tell you that up to 1 in 4 patients with chronic pain can experience opioid dependence, and depending on your risk factors - family history of addiction, mental health issues, other chronic issues - that can put you at higher risk.

SIEGEL: On the other hand, I say, I'm in agony here; my back is killing me.

HOURY: And what I would say is, let's try some other options first. We absolutely want to treat your pain, but we want to do it safely. If opioids are warranted, though, we're not saying use them in isolation. They should be used in combination with things like exercise therapy or a nonsteroidal medication.

SIEGEL: Some doctors have expressed concerns over the recommendation that limits the amount of opioids that doctors should prescribe. It limits them mostly to a three-days' worth quantity. Don't the guidelines make it difficult for people in that case who don't have easy access to a hospital or live in a rural area to get that prescription renewed?

HOURY: So we heard that feedback, and so there's now a range of up to seven days. We want to make sure patients have appropriate access, but we also want to limit the number of patients that become addicted. And having too many days of medication can put you at risk for addiction.

SIEGEL: One of the criticisms that was voiced about the first draft of the guidelines was that a lot of these are based on expert decisions but not on very clear experimental proof - just how effective the non-opioid drug is compared to the opioid drug. Is there room for more science here before guidelines get more detailed?

HOURY: So there's room for more science as we continue to revise and update the guidelines, but given the number of Americans - 40 dying a day from opioid overdoses - we have enough evidence today about the risks that we feel it is prudent to warrant guidelines today. That being said, I can tell you, as a practicing physician, many of the guidelines I use are often based on low-quality evidence. And that does not mean bad evidence. That just means there's not a lot of randomized controlled trials - things like handwashing, you know, after a viral illness (laughter).

SIEGEL: That (laughter) there aren't randomized studies of handwashing to show.

HOURY: Not with handwashing with a viral illness for treating patients, you know? And I don't think if somebody came in with vomiting and diarrhea and I didn't wash my hands after seeing them and seeing another patient that patients would appreciate that. But we know the risks are significant, and the benefits are great if I'm going to wash my hands. So things like that - a lot of the times common sense or the best available evidence we have - is what drives these decisions.

SIEGEL: There are doctors who treat a lot of patients with pain who have a stake in the guidelines coming out of the CDC. There are also pharmaceutical companies that make the medications that are being being prescribed. Have you felt in this process that you have either indirectly or directly been working against those drug companies in trying to draft new guidelines for prescribing opioids?

HOURY: So our focus has been on keeping deaths and addiction and safe pain management at the heart. We welcomed feedback from anyone and reviewed the 4,300 comments very carefully. Our goal is to improve outcomes for patients, and that's what drives the decisions we make.

SIEGEL: Dr. Houry, thanks a lot for talking with us today about the guidelines.

HOURY: Absolutely. Thank you for the opportunity.

SIEGEL: Dr. Debra Houry is the director of the National Center for Injury Prevention and Control at the CDC. She's been involved in developing the guidelines published today on the prescription of opioid medications. Transcript provided by NPR, Copyright NPR.