The CDC is preparing to release guidelines for opioid management and there is a lot of conversation surrounding them.
A draft of the recommendations can be read here and the guidelines can be summarized as limiting opioid prescriptions only to patients who cannot be effectively treated without them, careful monitoring to identify preexisting addiction, preventing new cases of addiction and, in most cases, limiting the dose of opioids prescribed by primary care physicians.
Limiting the dose of opioids prescribed is important because higher doses of opioids are linked to a higher risk of side effects including addiction, constipation, sedation, breathing problems and death. A frequent and valid complaint I hear among many pain specialists is being referred a patient who has been established on high-dose opioids inappropriately. This common situation might be reduced if the guidelines lead to a general reduction in dose.
Dose reduction is important because many patients who receive high-dose opioids are reluctant to decrease the doses they are on or to switch to other medication categories or management strategies. They have a higher risk of side effects and some have a sense of entitlement to a certain dose or quantity of opioids after having received it for weeks, months or years. There may also be emerging drug tolerance or addiction issues.
Complicating the whole debate is the scientific literature in which a consistent benefit from high-dose opioids is limited. In fact, much of the evidence suggests that the harm of a high-dose opioid strategy may exceed the benefit and that the patients who have received opioid-based treatment often have worse pain, more surgeries and more healthcare costs compared with similar patients who were not treated with opioids or were treated on lower doses.
The challenge of opioid prescription is it does decrease pain in the short term, but rarely has a long-term benefit and is fueling rising addiction and overdose deaths. Something so compelling in the short-term, but harmful in the long term is a challenge for the medical profession and a set of well-publicized guidelines are a good start to enhancing patient care and public safety.
Guidelines are most helpful when they represent a distillation of the best clinical evidence and do not prohibit physicians from properly treating patients with unique considerations who may benefit from treatment outside the boundaries laid forth by the guidelines. Due to the harm of opioids, the CDC guidelines are an important step to creating more constructive debate about how best to weigh the effective treatment of pain against the considerable risks of opioid medications.