CDC Formulates New Opioid Guidelines

(Spring 2016) The Centers for Disease Control and Prevention (CDC) released non-binding draft guidelines for physicians who prescribe opioid painkillers (e.g., OxyContin, Percocet and Vicodin) to patients ages 18 and older.  The drafted guidelines are not meant for the treatment of severe chronic pain or late-stage cancer patients. By issuing the guidelines, the CDC wishes to underscore the potential dangers, including addiction and death, of starting a patient on an opiate drug.

Opponents to the proposed guidelines say that they were hurriedly written behind closed doors and are short-sighted. CDC’s director Tom Frieden admitted that although there is limited evidence comparing various treatments, “There is no way we can wait for better evidence while so many people are dying.” In January, the guidelines were opened to public comments for 30 days.

Calling for a stricter approach to the drugs’ use, the CDC suggests physicians

• Manage chronic pain with alternatives such as physical therapy and non-opioid painkillers before writing an opioid prescription.
• Opt for short-acting formulations opposed to extended-releases versions.
• Prescribe the lowest possible dosage for the shortest period necessary (generally three days or less for acute pain).
• Keep opioid dosages to 50 morphine milligram equivalents (MMEs) per day.
• Within one to four weeks of beginning opioid therapy for patients with chronic pain or stronger doses, review benefits and harm as well as continue to evaluate them on a quarterly basis at a minimum.
• Require patients to submit to urine testing before receiving an opioid prescription and mandate that they do at least one annual urine test if they continue to take the medication. This will identify any patients who are already taking opioids or other illegal drugs
• Offer naloxone, an opioid overdose-reversal drug, to at-risk patients.

The American Society of Addiction Medicine (ASAM) supports the CDC’s recommendation and is pushing for the document to be finalized quickly. Additionally, the ASAM suggests that the original document also

• Apply not only doctors but also dentists and pain management specialists.
• Urge doctors to communicate to patients that physical dependence and tolerance are expected with opioid treatment and that this should be distinguished from addiction.
• Add more information on formulations of the drug naltrexone in the section on medication-assisted treatment for addiction (other than methadone and buprenorphine).

According to a recent survey, doctors are widely in favor of the CDC’s new proposal. Additionally, over 40% of the physicians polled support greater use of prescription drug monitoring programs (PDMPs) and advocate linking them across state lines. Sixty-three percent of the survey participants also report they are registered for their local PDMP. Many doctors are also in favor of increased education on proper prescribing practices and education for at-risk patients. Some cite the need for more access to naloxone as well as an increase in clean-needle exchange programs.

At the local level, officials with the State of Ohio back the CDC’s efforts to provide a framework for opioid prescriptions. However, on the other end of the spectrum nationally, the CDC’s stance on opioid painkillers is receiving a backlash from drug manufacturers, industry-funded groups, and some health officials. Leaders from the Food and Drug Administration (FDA) and other health agencies have labeled the guidelines as “short-sighted” and cite “low-quality evidence.” They plan to file a formal complaint.

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