Just a few days after a new report showed a surge of drug-related overdoses in 2014, the Centers for Disease Control and Prevention suggested in draft recommendations that physicians tackle chronic pain with other methods, such as physical therapy and non-opioid analgesics, before turning to the powerful medications. If opioids, such as OxyContin and Percocet, are necessary, the agency recommended short-acting versions over extended release formulations, the lowest possible dose and short-term prescriptions.
It also suggested that doctors ask patients to take urine tests before prescribing opioids and additional urine tests at least once a year if they continue on the drugs, to ensure that they aren't secretly taking other opioids or illegal drugs.
"What we want to just make sure is that doctors understand that starting a patient on an opiate is a momentous decision," said CDC director Tom Frieden. "The risks are addiction and death, and the benefits are unproven."
The draft guidelines were published in the federal register by a CDC committee that reviewed more than 100 studies on opioid therapy. They are not intended for doctors treating patients for severe chronic pain associated with diseases, such as late-stage cancer, or those providing end-of-life care. They are not binding on physicians.
"Primary care providers report concern about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction and report insufficient training in prescribing opioids," the panel wrote. The guidelines are an attempt to provide them evidence-based information for patients who need help with pain.
The nation continues to suffer through a widespread epidemic to prescription opioids and their illegal cousin, heroin. The CDC estimated that 20 percent of patients who complain about acute or chronic pain that is not from cancer are prescribed opioids. Health-care providers wrote 259 million prescriptions for the medications in 2012, "enough for every adult in the United States to have a bottle of pills," the CDC wrote.
Last week, the National Center for Health Statistics reported that the number of overdose deaths from legal opioid drugs surged by 16.3 percent in 2014, to 18,893, while overdose fatalities from heroin climbed by 28 percent, to 10,574. Authorities have said that previous efforts to restrict prescription drug abuse have forced some people with addictions to the medications onto heroin, which is cheaper and widely available.
Overall, deaths from drug overdoses reached 47,055 last year, a 7 percent jump from 2013, the data showed.
On Monday, Stanford University researchers who examined data from Medicare Part D prescribers reported that "by sheer volume...total prescriptions are dominated by general practitioners," not small groups of "prolific prescribers." General practitioners include doctors in family practice and internal medicine as well as nurse practitioners and physician assistants.
Yet the new guidelines noted that evidence for opioid use for "chronic pain outside end-of-life care remains limited, with insufficient evidence to determine long-term benefits."
Frieden said that some "prescribing patterns were formed at least in part by fraudulent marketing of prescription opioids" by drug companies. That was a reference to a 2007 settlement between Purdue Pharma and federal prosecutors, when a unit of the drug company and three top company executives pleaded guilty to “misbranding” OxyContin as less addictive than other narcotics. The company paid $634 million in fines.
Noting that "long-term opioid abuse often begins with treatment of acute pain," the CDC said that "three or fewer days" of opioid treatment "usually will be sufficient for most non-traumatic pain not related to major surgery."
And it suggested that before and during therapy with opioids, doctors should make "strategies to mitigate risk" part of their planning with patients, including offering the fast-acting antidote naloxone to people who have a history of substance abuse, a previous overdose or are taking high doses of the painkillers.
The CDC also called for primary-care doctors to closely monitor their patients' use of opioids by monitoring benefits and harms within one to four weeks of handing out the first prescription or increasing a patient's dose.
The guidelines themselves have been controversial since CDC began to distribute them to various interest groups in September. The Washington Legal Foundation, a public interest law firm dedicated to protecting the free enterprise system, accused the CDC of trying to formulate them secretly by failing to make public the work of its original advisory committee, the Core Expert Group. The CDC disputes that accusation, but issued the recommendations in draft form Monday and will have them reviewed by another advisory panel after receiving more comment over the next 30 days, Frieden said.
That will delay final adoption beyond the original goal of January. Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, said Monday that the delay is a victory for the pharmaceutical industry, which, he contended, has waged a "very well organized effort...to block release of the guidelines."
Representatives of the industry lobbying group--the Pharmaceutical Research and Manufacturers of America--and Purdue Pharma declined to comment.