Cancer & Chronic Pain: Doctors Urged to Stop Prescribing Opiates
The nation's top federal health agency urged doctors to avoid prescribing powerful opiate painkillers for patients with chronic pain, saying the risks from such drugs far outweigh the benefits for most people. The Centers for Disease Control and Prevention in its first ever guidelines for dispensing the morphine-like, addictive drugs, such as Vicodin and OxyContin, said it took the action Tuesday to combat the nation's deadly prescription painkiller epidemic.
The guidelines carve out an exception for patients receiving cancer treatment or end-of-life care. When doctors determine that such drugs are necessary in other situations, the CDC advises doctors prescribe the lowest possible dose for the shortest amount of time.
About 40 Americans die each day from overdosing on prescription painkillers, according to the CDC. In 2013, an estimated 1.9 million people abused or were dependent on prescription opiates.
"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," said CDC director Thomas Frieden. "We hope to see fewer deaths from opiates. That's the bottom line. These are really dangerous medications that carry the risk of addiction and death."
The CDC directed the guidelines to primary care physicians, who prescribe nearly half of opiates. Doctors aren't legally obligated to follow the recommendations, which are intended for adult patients, but such directives often have influence.
The CDC hopes the guidelines will help doctors determine when to begin or continue opiates for chronic pain, which type of painkiller to choose, how long to administer the drugs and how to weigh their risks.
Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, called the recommendations a "game changer" that doctors are likely to follow.
"For the first time, the federal government is communicating clearly that the widespread practice of treating common pain conditions with long-term opioids is inappropriate," Kolodny said. "The CDC is making it perfectly clear that medical practice needs to change because we’re harming pain patients and fueling a public health crisis."
American Cancer Society Cancer Action Network President Chris Hansen criticized the move for disregarding the important role of pain management for cancer survivors "who experience severe pain that limits their quality of life."
"Pain does not end when an individual completes treatment," he said in a statement. "Most often, cancer patients deal with lasting effects from their disease or treatment including pain for a significant period of time or indefinitely."
Many prescription opiates on the market are as addictive as heroin, and poorly control chronic pain, Frieden said. Doctors should use therapies other than opiates first, including exercise or non-steroidal anti-inflammatories, such as aspirin or ibuprofen, he said.
When the benefits of prescription opiates outweigh the risks, doctors should talk to patients about their treatment goals and when they will stop using the drugs. Due to a high risk of overdose, physicians should avoid prescribing opiates at the same time as benzodiazepines, such as anti-anxiety drugs Valium and Xanax. Doctors also should prescribe immediate-release opiates, rather than extended-relief tablets that are more likely to be abused.
Doctors petition FDA for 'black box' warning on combining painkillers, tranquilizers
Patients with acute pain, such as that caused by an injury, usually need prescription opiates for only three days. Prescribing the drugs for more than seven days is rarely necessary, he said.
"When opiates are used, start low and go slow," Frieden said, meaning doctors should increase the dose of medication slowly and only when necessary. Doctors should check every three months to see if the benefits of opiates still outweigh the risks, the guidelines said.
Telling patients and doctors that opiates are rarely needed for more than a few days "will help prevent patients from getting addicted and help keep highly addictive drugs from accumulating in medicine chests," Kolodny said.
If patients abuse opiates, doctors should help them get treatment supported by strong medical evidence, such as the therapies buprenorphine or methadone, which block or partly block the effects of opiates.
Advocates push to expand use of medications to treat addiction
The CDC's hard line on opiates is a major shift from conventional wisdom about relieving pain.
Although there has never been much evidence that opiates ease chronic pain, doctors were told for decades to consider pain as a "vital sign" that needed to be addressed, wrote addiction medicine specialist Yngvild Olsen, medical director of Reach Health Services in Baltimore, in an editorial in JAMA.
That advice to manage patients' pain was accompanied by "misleading marketing of prescription opioids by manufacturers, who minimized the risks of misuse and addiction," Olsen wrote. The pressure to manage pain led doctors to "miss or dismiss the presence of addiction in their patients," she added.
Patients should ask questions if their doctors want to prescribe opiates, said Deborah Dowell, senior medical adviser in the division of unintentional injury prevention at the CDC’s National Center for Injury Prevention and Control. Key questions to ask include: Is an opiate necessary? What are the risks? What are the benefits? How long should I take this? Are there alternatives? What we hope to accomplish by using an opiate? How will you know when we've met our goal?
Sen. Edward Markey, D-Mass. who has used Senate rules to block the nomination of the Food and Drug Administration chief over the agency's regulation of opioids, praised the CDC for releasing the guidance.
“Just as we need rules of the road to prevent injury and death, we need strong guidelines that can help prevent abuse of and addiction to opioid painkillers,” Markey said in a statement. “While these are important measures we need prescribers to take, they are just guidelines and we need requirements to ensure all prescribers of opioid painkillers are educated in safe prescribing practices and the identification of possible substance use disorders," Markey said.