With no end to the nation’s opioid crisis in sight, the federal government on Tuesday issued final recommendations that urge doctors to use more caution and consider alternatives before they prescribe highly addictive narcotic painkillers.
This first national guidance on the subject is nonbinding, and doctors cannot be punished for failing to comply. But the head of the Centers for Disease Control and Prevention, which issued the guidelines, said the effort was critical to bringing about “a culture shift for patients and doctors.”
“We are waking up as a society to the fact that these are dangerous drugs,” Director Tom Frieden said in an interview. “Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved.”
After record numbers of overdose deaths from opioid painkillers and heroin, 2016 may prove to be the year that the federal government begins to forcefully address what has become a major public health crisis. In addition to the CDC, the Food and Drug Administration is reassessing its policies on opioid medications, the Senate has passed legislation that would expand drug abuse treatment and prevention, and the Drug Enforcement Administration is pushing physicians for more responsible prescribing. The departments of Veterans Affairs and Defense already have opioid policies for their patients.
“For the first time, the federal government is communicating clearly that the widespread practice of prescribing opioids for chronic pain is inappropriate, that the risks outweigh the benefits,” said Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, a nonprofit that has been urging a curb on the use of opiates.
Given the CDC’s influence in the medical community, its recommendations are “a game changer,” Kolodny said.
Lawmakers who have faulted past federal efforts to tackle the addiction epidemic also welcomed the announcement.
“I have pushed for the release of these guidelines because I have seen firsthand the devastating effects of prescription drug abuse on individuals, families, and communities,” said Democratic Sen. Joe Manchin of West Virginia, which is one of the hardest-hit states. His statement called the guidelines “a critical part of our fight to end this epidemic.”
Priscilla VanderVeer, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, said the organization has “long supported policies that will help combat this critical public health issue, while also ensuring access to these medicines for patients with legitimate medical needs.” Such policies include expanded provider education and training on pain management and access to treatment options, she said.
Nearly 28,700 people died from overdoses of prescription opioids and heroin in 2014, according to the most recent data available. Since 1999, 165,000 people have fatally overdosed on prescription painkillers, the CDC said.
In just the past month, it said, 4.3 million have diverted the drugs for nonmedical uses.
“We know of no other medication routinely used for a nonfatal condition that kills patients so frequently,” Frieden and Debra Houry, director of the agency’s National Center for Injury Prevention and Control, wrote Tuesday in the New England Journal of Medicine.
The guidelines, which were delayed a few months by disputes with drug industry groups, are aimed predominantly at primary care physicians. These doctors prescribe many of the opioids but complain that they have insufficient training in how to do so.
Frieden agrees that many doctors need a refresher course on how to approach prescribing pain medications.
“When I went to medical school I had exactly one lecture on pain, and the lecture said if you give an opioid to a patient in pain, they will not get addicted,” Frieden said. “Completely wrong, and yet a generation of doctors grew up being taught that.”
The recommendations are not intended for doctors managing pain after cancer or surgery or during end-of-life care.
The CDC recommends that patients seeking help for pain first try non-opioid medications such as ibuprofen and acetaminophen whenever possible, as well as exercise and weight loss. If opioids are prescribed, low doses and less than a week’s supply should be provided. Currently, many doctors write prescriptions for oxycodone, hydrocodone and others to last patients several weeks or even a month.
“Three days or less will often be sufficient; more than seven days will rarely be needed,” the guidelines state.
The CDC advises clinicians to conduct urine tests of patients before starting opioid therapy and to test patients’ urine for the presence of controlled substances and illicit drugs at least annually.
Not many years ago, doctors were sometimes criticized for undertreating pain. But in 2012, after years of aggressive marketing by some drug companies, health-care providers wrote 259 million prescriptions for opioid pain relievers — enough for every adult in the country to have a bottle of pills.
Many patients now ask to be treated with opioids, Frieden said, and doctors who are worried about receiving low patient-satisfaction ratings often give in.
CDC officials stressed that in many cases, opioid drugs do a poorer job than other therapies in lessening pain. The agency is encouraging patients to question doctors who prescribe opioids for chronic pain.
Opioids “carry substantial risks but only uncertain benefits,” Frieden said. “The risks will outweigh the benefits for the vast majority of patients.”
Only about 5 percent of patients being prescribed opioid painkillers are receiving them for chronic pain. But that small group accounts for nearly three-quarters of opioid prescriptions. More than 70 percent of patients who die of opioid-related overdoses became addicted while being treated for chronic pain.
The recommendations also encourage doctors to monitor the effectiveness of the drugs they prescribe, to be on the lookout for dangerous drug interactions and to routinely check in with patients to make sure they aren’t abusing addictive prescription drugs or other illicit drugs.
Frieden said he expects that states and health insurers will incorporate some of the recommendations into their programs to help improve patient safety.