Doctors should not taper pain patients off opioid treatment too abruptly and should consider offering naloxone, an overdose-reversing drug, to patients who have a history of substance use disorder or will suddenly receive higher doses for which they haven’t developed a tolerance.
Those are some of the key points in updated guidelines the Centers for Disease Control and Prevention released Thursday to help doctors prescribe opioids for pain. It is the first major update since 2016 and incorporates new research on pain management while being mindful of the drug addiction crisis in America.
Officials went out of their way to highlight a part of the report that says opioid treatment for pain should not be discontinued abruptly, and that clinicians should not rapidly reduce dosages.
Patients who are cut off too fast can develop mental health issues, including suicidal thoughts. In some cases, they will seek out opioids in illicit markets if they are cut off in a haphazard way and experience withdrawal.
“It is a very real risk and one we wanted to ensure we highlighted,” said Christopher M. Jones, acting director of the CDC’s National Center for Injury Prevention and Control.
Chronic pain, defined as pain that lasts at least three months, impacts about 1 in 5 Americans, the CDC said. The guidelines are a long-awaited update that provides voluntary strategies — not rigid rules — for doctors who want to help individual patients.
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The guidelines also delve into when it is appropriate to use opioids for acute pain, which lasts one month or less, and subacute pain, which is defined as pain that lasts between one and three months.
In all cases, the CDC document said, “clinicians should prescribe the lowest effective dosage of immediate-release opioids for no longer than needed for the expected duration of pain severe enough to require opioids.”
The report said doctors should consider non-opioid treatments for acute pain, in particular, because many are just as effective as opioid treatments. Doctors should only consider opioid therapy for acute pain “if benefits are anticipated to outweigh risks to the patient,” the CDC said.
CDC officials said the primary purpose of the report was to help manage patients’ pain, but the broader context of the U.S. addiction crisis looms large over its release.
More than 107,000 Americans died from drug overdoses in 2021. It was the highest death toll ever recorded and reignited questions about social isolation from the pandemic and efforts to thwart deadly fentanyl from pouring over the borders.
Fentanyl, which is often trafficked from China and Mexico, is viewed as a kind of Russian roulette. Users often overdose on the highly potent synthetic opioid without realizing it has been mixed into other drugs.
Yet the overdose crisis shone a light on how people get hooked on opioids in the first place, and renewed scrutiny of prescribing practices. An uptick in prescribed painkillers in the 1990s and 2000s has been generally blamed for the U.S. opioid problem and led to lawsuits against drugmakers and distributors.
Dr. Jones said the main purpose of Thursday’s update is to help the millions of people who experience pain from medical conditions or procedures, although the CDC is mindful of the potential for opioid misuse or diversion into the wrong hands.
“I think we can pursue both of those at the same time,” Dr. Jones said.
Many states have taken steps to expand the use of naloxone, a drug that can be given by a simple nasal spray or injection to reverse overdoses. At least 17 states have passed laws requiring or recommending the co-prescription of naloxone with opioids if patients present certain risk factors.
The CDC guidelines said doctors should consider whether the patient or a household member is at risk of overdosing or if they are suddenly prescribing a higher amount of opioids.
“Clinicians should advise patients of an increased risk for overdose on abrupt return to a previously prescribed higher dose because of loss of opioid tolerance, provide opioid overdose education, and offer naloxone,” the CDC document says.
CDC officials also said the guidelines should help doctors streamline care so that it is equitable across geographic and ethnic groups — a key plank of the Biden administration’s health agenda.
“Geographic disparities contribute to increased use of opioids for conditions for which non-opioid treatment options might be preferred but are less available,” the CDC said. “For example, adults living in rural areas are more likely to be prescribed opioids for chronic nonmalignant pain than adults living in nonrural areas.”
It also said safeguards in opioid prescribing, such as restrictions on refills, have been disproportionately applied to Black patients even though White populations had higher rates of overdose deaths.
CDC said the new guidelines do not apply to treatment for sickle cell disease and cancer or end-of-life care. Other guidelines exist for those conditions.