CDC proposes new guidelines for pain treatment, including use of opioids

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The federal government on Thursday proposed new guidelines for prescribing opioid painkillers that remove its previous recommended caps on doses for patients with chronic pain and instead encourage doctors to exercise good judgment.

But the thrust of the recommendations was that doctors should first turn to “non-opioid therapies” for chronic and acute pain, including prescription drugs like gabapentin and over-the-counter ones like ibuprofen, as well as physiotherapy, massage and acupuncture.

Although still in draft form, the 12 recommendations, issued by the Centers for Disease Control and Prevention, are the first comprehensive revisions to the agency’s opioid prescribing guidelines since 2016. avoiding exposing patients to the well-documented dangers of opioids.

The 229-page document warns of addiction, depressed breathing, altered mental status and other dangers associated with opioids, but it also notes that the drugs serve an important medical purpose, particularly to relieve the immediate and acute agony of traumatic injuries such as burns and crushed bones. In cases where opioids appear to be the way to go, doctors should start with the lowest effective dose and prescribe immediate-release pills rather than long-acting pills, as recommended.

The recommendations are now open on the Federal Register for public comment for 60 days. The agency will review the feedback and most likely release a final version by the end of 2022. Like the 2016 guidelines, these are suggested practices, not mandatory.

“We welcome input from patients who live with pain every day and their caregivers and providers,” said Christopher Jones, project co-author and acting director of the National Center for Injury Prevention and Control, the CDC arm. who issued the new guidelines.

The guidelines do not apply to patients with pain related to cancer or sickle cell disease, or to patients at the end of life or in palliative care.

The 2016 guidelines have generated anger and fear among many chronic pain patients, many of whom rely on doses well above the recommended cap of 90 milligram equivalents of morphine per day. Hundreds of pain medicine specialists also protested.

Although dosage caps are only a recommendation, dozens of states have codified them. Fearing criminal and civil penalties, many physicians have misapplied them as rigid standards, cutting chronic pain patients too sharply and even cutting some of their practices.

Studies show that the number of opioid prescriptions overall has been declining since 2012, and the decline intensified after the 2016 guidelines were released.

The proposed new recommendations move away from the notion of a single dosage and instead incorporate “a flexibility to recognize that pain care needs to be individualized,” Dr. Jones said.

But the recommendations make it very clear that doctors should regularly reassess the benefits and risks of opioids.

“The evidence for the long-term benefits of opioids remains very limited,” Dr. Jones said.

In another indication that the CDC sees these new guidelines as a course correction from previous ones, the agency is now suggesting that when patients test positive for illicit substances, doctors should offer counseling, treatment and, if necessary, a careful reduction. Because doctors had interpreted the 2016 dosage limits narrowly, some had developed one-shot policies and were summarily expelling such patients.

Dr Jones said these results should rather be seen as diagnostic information among others. An excessively high level of opioids could indicate that the patient is still suffering from untreated pain or even a substance use disorder. “If you instead retain the patient and have these conversations, now there is an opportunity to improve the patient’s life,” he said.

Drawing on a mountain of research accumulated over the past few years, the proposed guidelines also offer detailed recommendations for the treatment of acute pain – short-term pain that can accompany an injury such as a broken bone or the aftereffects of a surgical intervention. They advise against prescribing opioids except for traumatic injuries, such as burns and car accidents.

In detail, they compare the relief provided by opioids to that provided by alternatives such as exercise, acupuncture and other medications. And they give specific recommendations for discrete areas of pain, such as the lower back, knees, and neck.

The guidelines, for example, note that opioids should not be used for episodic migraines. They endorse, among other treatments, heat therapy and weight loss for knee osteoarthritis, and for neck pain, suggest options like yoga, tai chi, qigong, massage, and acupuncture.

The recommendations also state that numerous studies show that over time, pain relief from opioids generally plateaus and then declines, requiring ever-higher doses.

“We never wanted to pretend that opioids aren’t really important tools,” said Dr. Jeanmarie Perrone, professor of emergency medicine at the University of Pennsylvania’s Perelman School of Medicine, who served on an advisory committee for prescribing guidelines. “But after you have this cast, we are going to wean you off these opioids. A long bone fracture does not mean six weeks of opioid prescriptions.


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