Millions of people in the United States — an estimated 3 to 4 percent of the adult population — take opioids daily. About 2 million people have been diagnosed with prescription opioid use disorder, according to HHS. There is a consensus in the medical community that these painkillers have been overprescribed and that many patients would have better long-term health outcomes if they cut back on their dosages and took advantage of other types of treatment, ranging from physical therapy to nonnarcotic painkillers.
But there has been pushback from people in pain. Many say they desperately need the opioids they take and don’t want to be forced by their doctors to taper the dosages. Many also are anxious about the prospect of losing access to their painkillers.
People who have been forced by their doctors to cut back rapidly on their medication may experience heightened pain and may suffer psychological distress, the new HHS guide for clinicians states. Clinicians are advised to monitor patients closely for signs of anxiety and suicidal ideation.
“Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress and thoughts of suicide. Patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms,” states the HHS guide.
“Increased pain happens to be an opioid-withdrawal symptom. Most patients will experience a transient experience of pain,” said Deborah Dowell, a chief medical officer at the Centers for Disease Control and Prevention and the lead author of the new guide.
“All of us are extremely empathetic to people living with severe chronic pain,” Giroir said.
He reiterated the need to take steps to limit opioid addiction and reduce the number of fatal overdoses. That can be done while still treating pain with opioids in a responsible manner, he said. “We can achieve both goals. They are not mutually exclusive.”
This is a delicate issue for the millions of people taking opioids and the broader medical community, which in the 1990s embraced the idea of pain as the fifth vital sign of health. Drug companies promoted opioid painkillers as a safe and rarely addictive treatment for chronic pain. Pills such as OxyContin and Percocet began to be used widely for pain from back injuries, arthritis or headaches.
The overuse of these pills and patches has fueled an opioid epidemic that claims more lives every year in the United States than automobile accidents or gun violence. In the past decade, medical experts have come to realize the potentially dire consequences — addiction, for starters, overdoses, and death in the worst-case scenarios — of prescribing these narcotics for ailments other than cancer, recent surgery or end-of-life palliative care.
A 2016 guidance from the CDC set standards for prescribing of opioids. Officials later acknowledged that many medical professionals misinterpreted the guidelines.
The CDC, for example, had suggested an upper limit for opioid dosages among new patients. But many patients were already taking more than that, and their doctors tried to cut dosages to the CDC recommendation. The CDC clarified the guidance earlier this year to say that it only applied to new patients, not existing ones, who should not be tapered rapidly to a lower dose.
“Clearly we believe that there has been misinterpretation of the guidelines, which were very clear. The guidelines do not recommend opioid discontinuation, certainly not to do it abruptly,” Giroir said.