So Lennihan / AP
Physicians will soon receive additional guidelines from the Centers for Disease Control and Prevention on how and when to prescribe opioids for pain.
Those guidelines – currently being viewed in more detail – will be a new addition to the department’s previous guidelines on opioids, released in 2016. That statement has been widely criticized. and for leading to adverse outcomes for patients with chronic pain.
Federal officials are aware of their frequently used basic guidelines; It is intended to serve as a pathway for doctors to make difficult decisions about opioids and pain – not as a set of rules.
But the 2016 power has been used as a basis for making policy decisions, as judges and health leaders have struggled to contain the nation’s overdose problem. Many states have adopted laws and regulations to set limits on exposure, and health care providers have also developed policies to that effect.
And doctors have been wary of prescribing opioids, which have often led to immediate cessation of care, resulting in physical and mental harm, and a sharp rise in homicides.
A firm approach to referral has been maintained, said Cindy Steinberg, director of public policy and support for the U.S. Pain Foundation..
“I get sick every week and doctors don’t want to see sick patients,” he said. “It’s a very difficult situation out there.”
That is why revised leadership is considered. The public opinion period ends on Monday, and then the industry will weigh in on its final recommendations.
Some experts see the changes as a promise to address the risks of post -traumatic stress disorder. And many others, including patients with chronic pain, argue that leadership is inadequate – and that it can be misunderstood and misused.
There are steps in the right direction
The new guidelines – a comprehensive, 200 -page document – are expected to continue advising against the use of opioids for pain if possible and take precautions when necessary, given the risk of stroke. opioid abuse and overdose.
But there are some important changes from the old leadership.
High -dose counseling – often taken for physicians and policy makers – no longer puts specific limits on the amount and length of opioid counseling a patient can take.
“That’s a big change,” Drs. Stefan Kertesz, doctor of medicine at the University of Alabama at Birmingham.
With basic leaders, “insurance companies and regulators that capture those numbers have been turned into simple tools to push for changes in infrequent care that is not safe for patients,” he said.
New leaders also recognize that physicians need to use their own judgment in determining the safe and effective outcome for each patient. The authors previously stated that it was not “intended to be used as a standard form of care” or as a “law, regulation or policy governing medical practice.”
Kertesz believes it is important to be aware of the misuse of primary care, especially in patients in the form of opioids for chronic pain.
“The CDC’s commitment to improvement has been a real effort without losing the authenticity of these drugs that have been widely used and oversold for years,” he said.
In fact, the guidelines are intended to steer physicians away from using opioids as a primary treatment for many common pain disorders – among them, low back pain, musculoskeletal injuries and with pain associated with small cuts. He also stops using opioids for chronic pain, but realizes that opioid medication can play a role in treatment, even if other methods are tried.
“We’re trying to explain the fact that these hard thresholds weren’t considered,” Drs. Roger Chou is at Oregon Health & Science University and is the author of 2016 Leadership and Innovation.
Chou notes that reports consistently show that opioid abuse and overdose are on the rise with increasing amounts and that the benefits seem to be minimal. However, he said their 2016 guidelines were often used in the ways they taught, for example for patients with chronic cancer.
“Sometimes it’s hard to know how to sue the leader for that?” his place. “We’ve tried our best now to be clear – it’s easier than ever. ”
Not too far
According to some patients and physicians, it is impossible to address the problems of traumatized patients.
“I don’t think it will go very long to protect patients from the inhumane trauma that these leaders have inflicted on the last six years,” Steinberg said.
Leaders are inconsistent when discussing decisions about starting and stopping opioid medication, he said, with a focus on the “dangers of opioids,” he said. There are no benefits when the medication is administered, or the risks and dangers of poorly treated pain. ”
Steinberg would like to see strong language against abandoning patients who rely on opioids for pain.
Dr. Sally Satel, who has studied the effect of opioid prescribing rules on injured patients, said she was concerned about advice for lowering the doses of opioids, or tapering. They think not to turn a taper while progressing, which he thinks could lead to disaster.
In addition, the “admonition” that opioids are not a good treatment for non -painful pain “lowers the physician’s mindset and the care that is guaranteed to lead,” said Satel, a senior fellow at the American Enterprise Institute.
Satel saw some positive changes in the new document, but in the end it felt it was running into some of the same problems as the previous version – pointing out specific points in the document that would which can give the impression of a “barrier” when prescribing opioids.
“Every message that comes together can be translated in a bad way,” he said.
Questions about the impact of leaders
Many of the challenges posed by traditional guidance have to do with discontinuing care for people on long -term opioids.
But for severe pain or post -traumatic stress disorder, removing specific dosing thresholds and the number of days to complete a prescription is a “problem,” Drs. Gary Franklin is a research scientist at the University of Washington.
He defended the 2016 leaders, saying they were good because they gave clear pieces to doctors who weren’t comfortable prescribing opioids, and didn’t know how to drive decisions. about pain management.
“If you take that help in opening the specific guide, it will make them more comfortable. They don’t know what to do, ”Franklin said.
Before lowering its guidance, the CDC should issue two recommendations, he said, one for those who are starting opioids and the other for those who are already on opioids.
Franklin, who is also the medical director of Washington’s state workers’ compensation program, was one of the first to raise awareness about the rising use of opioids and drugs. its link to overdose death.
“It’s the worst disease that man has ever created in the history of modern medicine – and it’s been created by us, the doctors, by the substitutes for the drug companies,” he said. “We’re trying to think, how do you turn this around?”
However, some argue that prescriptions may have a small effect on the overdose problem. Opioid prescriptions have been rejected by more than 40% in the past decade – a trend that began before the CDC released its 2016 guidelines. Now, the death toll has risen. the U.S. drug industry, which reached an all -time high last year, with more than 100,000 people dying.
It’s the drugs on the road like fentanyl that are leading the way. Prescription opioids will account for about 16,400 of the more than 91,000 fatal overdoses by 2020.
While CDC leaders may have reduced the reference, “what they haven’t done in the long run is to reduce the number of deaths,” Drs. Sebastian Tong, an addiction physician in Washington DC
It is unbearable pain for the sick
Experts note that even with a change in leadership, the consequences can be difficult to prepare for, the consequences of which are associated with requiring some patients to suffer severe pain.
Amanda Votta said she began to have trouble getting doctors to prescribe her opioids “very similar to CDC guidelines.”
Votta, 41, was diagnosed with rheumatoid arthritis, an autoimmune disease, when he was 10 years old. Her condition did not respond well to treatment.
“I have a problem that constantly develops bone pain in the bone,” said Votta, who has taken opioids to control his pain all his life. “I always took them as directions. I wasn’t branded as misusing my instructions.”
Following the release of the CDC guidelines, her primary care physician was unhappy with the prescription of oxycodone and the availability of a provider to treat her pain. He was a graduate student and did some work on campus.
“There were times when I would go and sit in one of the little cubbies of the library and just cry because I was in so much pain,” he recalled. “It was unbearable.”
Pain patients like Votta have a hard time getting prescribed opioids. In many places, primary care physicians will not allow new patients to require medical treatment.
Last year, about 20,000 patients in California were left without pain management when their clinics were closed, and those on long -term opioid treatment given a 30 -day supply only, according to a new article in the New England Journal of Medicine.
“Patients quickly realized that their primary care physicians were reluctant to prescribe opioids. Patients without a physician now realized that almost no one could prescribe opioids to new patients, and not at all. some will prescribe opioids, ”the authors write.
The dissatisfaction among physicians is also related to the increased scrutiny of their reference services to state electronic databases. State drug boards and federal law enforcement agencies can investigate people who are diagnosed with prescribing more opioids than their peers.
Kertesz said he was aware of the Drug Enforcement Administration directing opioid prescribing doses as part of the CDC’s 2016 guidelines (although Kertesz has not been involved in any cases himself).
“You can imagine having a happy ending,” he said.
However, he said, CDC guidelines could not be held to account for universal “abuse” of patients because doctors, administrators, administrators and complainants responded in a way that Better than what the scripture calls for.
He believes the new leadership will lead to necessary changes to existing laws and policies but says it is difficult to predict.
“Of course, bureaucracies don’t finish what they did quickly,” he said.