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New guidelines for prescribing opioids

By Lenny Bernstein

The Washington Post

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The government on Monday urged primary-care physicians who prescribe opioids for pain relief to rein in their use of the drugs, proposing new guidelines that call for a more conservative approach than the one that has led to a crippling epidemic of addiction to the powerful narcotics.

Just a few days after a new report showed a surge of drug-related overdoses in 2014, the Centers for Disease Control and Prevention suggested in draft recommendations that physicians tackle chronic pain with other methods, such as physical therapy and non-opioid analgesics, before turning to the powerful medications. If opioids, such as OxyContin and Percocet, are necessary, the agency recommended short-acting versions over extended release formulations, the lowest possible dose and short-term prescriptions.

It also suggested that doctors ask patients to take urine tests before prescribing opioids and additional urine tests at least once a year if they continue on the drugs, to ensure that they aren’t secretly taking other opioids or illegal drugs.

“What we want to just make sure is that doctors understand that starting a patient on an opiate is a momentous decision,” said CDC director Tom Frieden. “The risks are addiction and death, and the benefits are unproven.”

The draft guidelines were published in the federal register by a CDC committee that reviewed more than 100 studies on opioid therapy. They are not intended for doctors treating patients for severe chronic pain associated with diseases, such as late-stage cancer, or those providing end-of-life care. They are not binding on physicians.

“Primary care providers report concern about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction and report insufficient training in prescribing opioids,” the panel wrote. The guidelines are an attempt to provide them evidence-based information for patients who need help with pain.

The nation continues to suffer through a widespread epidemic to prescription opioids and their illegal cousin, heroin. The CDC estimated that 20 percent of patients who complain about acute or chronic pain that is not from cancer are prescribed opioids. Health-care providers wrote 259 million prescriptions for the medications in 2012, “enough for every adult in the United States to have a bottle of pills,” the CDC wrote.

Last week, the National Center for Health Statistics reported that the number of overdose deaths from legal opioid drugs surged by 16.3 percent in 2014, to 18,893. Authorities have said that previous efforts to restrict prescription drug abuse have forced some people with addictions to the medications onto heroin, which is cheaper and widely available.

On Monday, Stanford University researchers who examined data from Medicare Part D prescribers reported that “by sheer volume … total prescriptions are dominated by general practitioners,” not small groups of “prolific prescribers.” General practitioners include doctors in family practice and internal medicine as well as nurse practitioners and physician assistants.

Yet the new guidelines noted that evidence for opioid use for “chronic pain outside end-of-life care remains limited, with insufficient evidence to determine long-term benefits.”

Frieden said that some “prescribing patterns were formed at least in part by fraudulent marketing of prescription opioids” by drug companies. That was a reference to a 2007 settlement between Purdue Pharma and federal prosecutors, when a unit of the drug company and three top company executives pleaded guilty to “misbranding” OxyContin as less addictive than other narcotics. The company paid $634 million in fines.

Noting that “long-term opioid abuse often begins with treatment of acute pain,” the CDC said that “three or fewer days” of opioid treatment “usually will be sufficient for most non-traumatic pain not related to major surgery.”

And it suggested that before and during therapy with opioids, doctors should make “strategies to mitigate risk” part of their planning with patients, including offering the fast-acting antidote naloxone to people who have a history of substance abuse, a previous overdose or are taking high doses of the painkillers.

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