Pain Specialists Pile on CDC Opioid Guidelines

Chronic pain patients were left out to dry

https://www.medpagetoday.com/meetingcoverage/painweek/81995

LAS VEGAS — The 2016 CDC guidelines on opioid prescribing have had lasting consequences for patients with chronic pain, an expert said here.

In the 3 years since the guidelines were published, at least 33 states have enacted legislation that limits opioid prescribing, and although half of these states specify that the new limits are intended for patients with acute pain, many physicians have stopped prescribing opioids to chronic pain patients as well, according to Gary Jay, MD, of the University of North Carolina in Chapel Hill.

“[The guidelines] added to the burden of chronic pain patients who use — not abuse — medications,” Jay told a standing-room-only crowd here at PAINWeek. “Because without their medications, they’re unable to function.”

In April, the authors of the guidelines stated that the recommendations were not intended to force hard limits of opioid doses, abruptly taper or stop opioid use, or be applied to patients outside the guidelines’ scope, such as patients undergoing active cancer treatment or, in some cases, patients with chronic pain.

“The guideline is not intended to deny any patients who suffer with chronic pain from opioid therapy as an option for pain management,” wrote Deborah Dowell, MD, MPH, of the CDC, in Atlanta, in the form of a letter. “Rather, the guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options for patients.”

Around the same time, the FDA also advised against rapidly tapering or ceasing opioid use based on the known harms of doing so.

But these announcements came as “too little too late,” Jay said.

In effect, the guidelines have left many high-impact chronic pain patients, who commonly have difficulty accomplishing work and self-care activities, “essentially function-less,” Jay said.

Thomas Kline, MD, PhD, a known advocate for chronic pain patients, has compiled a list of 40 patients who have died by suicide associated with forced tapering of opioids.

Jay said anecdotally that he has had patients who have done so.

Meanwhile, the discontinuation of prescription opioids may lead other chronic pain patients to turn to the street to obtain heroin or other illicit drugs to control their pain, Jay said.

“When nonfunctional patients as well as recreational drug users couldn’t access oxycodone, they found something else: heroin,” Jay said.

While overdose deaths from any opioid have increased dramatically since 2009, the number of prescription medication overdose deaths has remained low, Jay said, suggesting that other drugs, like synthetic fentanyl and heroin, are driving the epidemic.

The number of opioids being prescribed is also decreasing, despite the increase in opioid-related overdoses, he added.

“We have been told the ‘opioid crisis’ was secondary to the ‘prescription opioid crisis’ and an ‘addiction crisis,’ but these statements have never been backed up with evidence,” he said. “It is clear that the overdose deaths were the result of polypharmacy and illicit fentanyl or other illicit or illegally obtained drugs.”

All but one of the guidelines received category “A” recommendations, but are supported by the two lower categories of evidence, which rely on observational studies, randomized trials with severe limitations, or clinical observation.

According to the guidelines, they were designed to “reduce the risks associated with long-term opioid therapy, including opioid use disorder,” by reducing prescription opioids.

But while the National Institute on Drug Abuse reports that 8-12% of patients on long-term opioid therapy develop an opioid use disorder, the evidence supporting this association is mixed, Jay said. Other reports show rates of opioid abuse following long-term opioid therapy to be as low as 0.6%.

Addiction, a complex condition with a genetic basis, also differs from tolerance and physical dependence, Jay noted. In patients with genomic changes, opioid addictions can form immediately after their first exposure; just one pain pill will induce the addiction, he said.

However, in 2013, the American Psychiatric Association updated the Diagnostic and Statistical Manual of Mental Disorders, consolidating substance abuse and substance dependence into “substance use disorder.” Patients with high-impact chronic pain, therefore, may fall under this definition, since they are dependent on their medication to function, Jay said.

But despite the backlash the guidelines have received from professional organizations and patients, little has been done to change them, Jay concluded.

“Months after the FDA and CDC statements, pain physicians and pain patients are still not sure if anything changed,” he said. “While they stated the guidelines were used inappropriately, nobody has made them appropriate.”