March 21, 2016

Guidelines for Opioid Painkillers May Fall Short of Addressing Needs of Rural Populations: Part I

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EDITOR’S NOTE: This is the first installment in a two-part series that assesses the impact on America’s rural health population of the CDC’s guidelines for prescribing opioid painkillers.

An epidemic 10 years in the making that kills more than 40 Americans every day, with overdose deaths soaring as high as 47,055 in 2014, has finally resulted in the Centers for Disease Control and Prevention recently publishing guidelines in the Journal of the American Association to set national standards on how clinicians are to administer drugs and curb overdoses of prescription opioids. This move comes after medical organizations and states established their own restrictions to address the epidemic, and after recent plans and announcements by the White House, Congress, the U.S. Department of Health and Human Services (HHS).

This public health epidemic has been exacerbated by the fact that healthcare providers as a whole wrote 249 million prescriptions for opioid painkillers in 2013 alone, representing prescription pain medication sales totaling $20.4 billion in 2014. This trend recently necessitated heightened actions for discussion, funding, debate, legislation, and guidance, including the U.S. Senate’s move to pass a bill last week that would provide financial assistance via grants for states and local authorities to address prescription drug and heroin abuse, prevention, and treatment.

So it comes as no surprise that the CDC would take such a position in an effort to reduce addiction. The CDC guidelines, which are not binding and are endorsed by many addiction experts, essentially serve as recommendations – or, as CDC Director Thomas Frieden noted, “a tool for doctors and for patients to chart a safer course.”

This includes the following steps:

  1. Encouraging primary-care clinicians – doctors, physician assistants, and nurse practitioners – to use more caution in prescribing opioids/powerful painkillers to treat chronic pain (pain lasting longer than three months) such as back pain or arthritis.
  2. Having physicians first recommend non-opioid anti-inflammatory drugs such as aspirin or ibuprofen for chronic pain.    
  3. Having physicians offer alternative means for pain management such as physical therapy.
  4. Having physicians limit opioid prescriptions for patients with short-term acute pain to doses lasting three days or less, reinforcing the “smallest amount of prescription for the shortest amount of time.” Currently, many physicians prescribe painkillers for two weeks to a month.
  5. Ensuring that patients take urine tests before receiving prescriptions and physicians check prescription drug monitoring information to be certain that patients are not being double-prescribed and receiving prescriptions from other physicians for their chronic condition(s). This is especially important for the subset of physicians who write 50 percent of prescriptions for opioid painkillers. As the CDC has noted, “chronic pain patients account for 70 percent of opioid prescriptions” (it is important to note that even though 49 states have established this system, only 16 states require that doctors use them).
  6. Ensuring that guidelines don’t apply for terminal illnesses, cancer treatment, or palliative or end-of-life care.
  7. Establishing clinical “checkpoints:” treatment goals, going over harms and risks, etc., all aimed at breaking the standardized prescription procedures that plague the overburdened healthcare system.
  8. Creating an overall more transparent approval process for opioid drugs, including improved communication with the medical community about the risks associated with these drugs and safe prescribing practices, as well as increased access to information about the risks of misuse and abuse associated with long-term opioid use.

Some no doubt will say that these recommendations are just that, merely recommendations, adding that the problem isn’t new or surprising at all, because opiates have been used and abused dating back to the ancient Sumerians (3,400 BC), when wild opiates (poppies) were described as the “joy plant.”

Through the passage of time came waves of subsequent addictions, such as in 1908, when it was found that one in every 400 Americans were addicted opium users, two-thirds of them women. This resulted in a wave of legislation: The 1914 passage of the Harrison Act, for example, which zeroed in on opium supply chains, levying heavy taxes and ordering sellers to register with the government. There was also the 1919 Supreme Court ratification banning physicians from giving opioids to addicts except to wean them from their ways; plus the Heroin Act of 1924, the 1951 Boggs Act, and the Controlled Substance Abuse Act of 1970. 

So while progress was made, in the 1990s into the 2000s the “chronic pain movement” was born. Suddenly the medical community began treating an era of undue suffering and pain due to recent surgeries, misidentified or unidentified ailments, and old injuries, and this gave way to accelerated opioid prescriptions. Data shows that 165,000 people died due to prescription opiate overdoses from 1999 through 2014. Because there is such a fine line between a therapeutic dose and a dangerous dose of an opioid, finding a balance will continue to be difficult. 

Clinicians already take the Hippocratic Oath to first “do no harm,” but what do the CDC guidelines really mean for them? Yes, they certainly will pay attention to what the CDC recommends, but, perhaps they could or should have heard the message sooner, for the sake of their patients.

A few things to remember:

  1. Clinicians need to understand that the limits on opioid quantities for acute pain aren’t mandatory.
  2. They also need to take into account weighing the pros and cons of administering these drugs, keeping in mind that while three days or fewer of opioid medication might be fine for pain caused by minor injuries in cases of trauma, larger quantities could last weeks, and therein lies the risk for appropriate pain medication management.
  3. Clinicians need greater information and often training to allow them to understand the full spectrum of pain management and addictive behaviors.
  4. Clinicians need to look at other pioneering methods of treating this epidemic, such as patient genetic screenings.

Stay tuned to see where this goes, from Capitol Hill to HHS to the White House to the CDC to rural communities. 

About the Author 

Janelle Ali-Dinar, PhD,  is the chief operations officer at MedFirst Partners and a senior rural health expert at Healthcare Solutions Connections. She has more than 10 years of experience in rural health policy, legislation, strategy, and operations, having served on the National Rural Health Association’s national rural congress. Dr. Ali-Dinar is also an NRHA Rural Fellow. 

Contact the Author 

drjalidinar@yahoo.com 

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