Opioids Crisis: You Can Help Advocate for New Federal Prescription Guidelines

Government wants thoughts on why guidelines are needed

Calling all recovery advocates and other citizens concerned about the national opioids crisis: It’s time to be heard.

We have an important but relatively brief opportunity to speak into a proposal that seeks to address the problem at its root—by encouraging safer prescribing practices.

The class of drugs known as opioids includes prescription pain medications like morphine, Vicodin and Oxycontin, to name a few. It also includes heroin, a cheaper "street" opioid that has a similar effect on the mind and body as the prescription varieties. Overdose deaths related to opioid addiction have reached epidemic proportions in recent years.

Back in September, the Centers for Disease Control and Prevention (CDC) responded by drafting 12 guidelines designed to help primary care doctors treat chronic pain effectively without creating unnecessary risk of addiction. It's a nonpartisan issue and, in my estimation and that of the Hazelden Betty Ford Institute for Recovery Advocacy, a rather modest yet helpful proposal. It's not a mandate. It includes no black-and-white requirements. It doesn't even apply to active cancer treatment, palliative care for other serious illnesses, or end-of-life care.

And yet it's under attack from chronic pain patients and organizations that represent them, as well as some physician groups—all of whom have delayed the planned January release of the guidelines by insisting on a public comment period, which will then be followed by potentially months of analysis. Apparently, the plan did not originally call for laypeople to weigh in on expert-developed medical guidelines. To me, that doesn't seem so strange. However, critics fear the guidelines will chill prescribing practices too much, leaving people with chronic pain to suffer needlessly. I empathize with such fear. But after actually reading the guidelines, I feel the proposal is more likely to bring about a balanced approach than to swing the pendulum too drastically.

Like so many other Americans, I am personally connected to this issue. My mother was a 20-plus-year chronic pain sufferer, who accidentally overdosed and died in March 2015 due to her opioid use disorder. I experienced up close the frustratingly complex interplay of her two conditions. As a result, I have always qualified my cry for an end to over-prescribing with measured concern for the chronic pain patient. I don't want to overcompensate and start stigmatizing pain. At the same time, I know we need to think about pain differently. I know we need to do more to actually treat pain—rather than mask it—and to minimize harm.

My mom eventually got to the point where she could not get off her pain medications without investing in long-term holistic co-occurring treatment for her opioid use disorder and pain. It was too late for her primary care doctors to simply change her medications. Even she acknowledged, in vulnerable moments, that her mistake was in starting long-term opioid therapy in the first place, because it only contributed to her declining health over time.

While people who are already dependent after years of opioid therapy cannot be abruptly cut off without some other intervention, these guidelines could very well help prevent the next generation of opioid use disorders and could help bring our approach to pain into balance. The guidelines are no panacea, but one valuable root-cause solution in a broad national fight to end the opioids crisis.

I urge you to read for yourself the 12 draft guidelines at the bottom of this blog. If you think they are a thoughtful and reasonable response to the nation's opioids crisis—one that could lead to safer prescribing practices and ultimately help pain patients—then please consider adding your voice to those commenting on the federal register notice. When the comment period opened December 14, pain patients rallied to fill the comments with their perspective. 

They no doubt will continue to do so. But the other side of the story needs to be shared too—by those who have experienced their own or a loved one's opioid addiction and those professionals who have treated it. 

The comment period ends January 13, but don't wait. It only takes a minute or two to record your thoughts. Let's show how much we care about confronting the opioids crisis. If we don't, this important effort could be delayed even longer, or worse—scuttled altogether.

As you consider your comments, remember the guidelines are a response to these troubling facts, gleaned from CDC and other sources:

259 million opioid prescriptions written in U.S.

in 2012 alone

America consumes 80% of world's opioids

with only 5% of population

2 million Americans misusing or dependent on opioids

in 2013

300% increase in U.S. prescription opioid sales

since 1999

Heroin use often begins with prescription painkillers

indeed, 75% of the time

29,000 opioid overdose deaths in 2014

18k due to prescription opioids and 11k due to heroin

You can read the CDC's full 56-page proposal, which includes detailed evidence and explanations for the 12 guidelines, collectively intended to:

  • “Improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain,
  • "Improve the safety and effectiveness of pain treatment, 
  • "And reduce the risks associated with long-term opioid therapy.”

You also may find, like I did, that the guidelines are sensible on their face and that they very much reflect the intent stated above. By all means, judge for yourself:

  1. Non-pharmacological therapy and non-opioid pharmacological therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.

  2. Before starting long-term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

  3. Before starting and periodically during opioid therapy, providers should discuss with patients risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

  4. When starting opioid therapy, providers should prescribe short-acting opioids instead of extended-release/long-acting opioids.

  5. When opioids are started, providers should prescribe the lowest possible effective dosage. Providers should implement additional precautions when increasing dosage to 50 or greater milligrams per day in morphine equivalents and should avoid increasing dosages to 90 or greater milligrams per day in morphine equivalents.

  6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days will usually be sufficient for non-traumatic pain not related to major surgery. 

  7. Providers should evaluate patients within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients receiving long-term opioid therapy every 3 months or more frequently for benefits and harms of continued opioid therapy. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids when possible.

  8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid-related harms are present.

  9. Providers should review the patient’s history of controlled substance prescriptions using state Prescription Drug Monitoring Program data to determine whether the patient is receiving excessive opioid dosages or dangerous combinations that put him/her at high risk for overdose. Providers should review Prescription Monitoring Program data when starting opioid therapy and periodically during long-term opioid therapy (ranging from every prescription to every 3 months).

  10. Providers should use urine drug testing before starting opioids for chronic pain and consider urine drug testing at least annually for all patients on long-term opioid therapy to assess for prescribed medications as well as other controlled substances and illicit drugs.

  11. Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible.

  12. Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.

I hope drug companies and those with financial connections to them are not behind the barrage of attacks against these guidelines. But many believe that is the case. I also fear some opponents have not read the 12 guidelines, which are admittedly rather difficult to find. And so, we share them here and invite you to join us and others who are fighting this epidemic. 

Submit your comments on the federal register notice today and then please pass along the link to help others do the same. 

Jeremiah Gardner, Mgr of Public Affairs and AdvocacyJeremiah Gardner, manager of public affairs and advocacy at the Hazelden Betty Ford Foundation, is a person in long-term recovery with a master's degree in addiction studies and a background in journalism, public affairs, business and music.
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