New guidelines from the country’s foremost health agency that caution against prescribing opioids as the first choice to treat chronic pain are being embraced by doctors in West Virginia, the center of the opioid addiction epidemic.
The Centers for Disease Control and Prevention issued new recommendations Tuesday for health care providers on prescribing opioids for treating pain outside of cancer treatment and palliative care.
The guidelines recommend that doctors avoid opioids as a first choice in treating musculoskeletal pain and should attempt to treat pain without medication or without opioid medication. When opioids are deemed necessary, they should be given in the lowest possible dose and with clear plans for how long they will be administered.
According to the CDC, 20 percent of patients who complain of pain not related to cancer are prescribed opioids, and the rates of opioid prescribing vary greatly from state to state without corresponding health factors.
Dr. Carl “Rolly” Sullivan, director of the addiction program for WVU Medicine, said the guidelines offer doctors a guidepost for moving away from the opioid overprescribing that has become the norm in the last 20 years.
“I’m a lifelong addiction doctor in West Virginia, and I was ecstatic to see the CDC take a very firm and very coherent stance on the problem of prescription opioids,” Sullivan said. “It gives doctors, residents and medical students a blueprint from which we can work, so that we can start to deal with this more effectively.”
West Virginia Attorney General Patrick Morrisey was among a group of 35 attorneys general who joined in supporting the CDC’s proposed guidelines in January. On Wednesday, Morrisey’s office said the attorney general plans to announce best practices pertaining to the prescription drug supply chain.
“Prescription drug abuse is an epidemic in West Virginia,” Morrisey said. “I recognize these guidelines are voluntary, but such guidance is only as good as those who follow it. That’s why I call upon doctors, hospitals, insurers and government regulators to act quickly in hopes these recommendations will save lives and prevent others from getting hooked.”
Sullivan said one important facet of the CDC’s recommendations is its stance on long-term opioid use and pain — prolonged opioid use has been linked to increased pain sensitivity, and there is very little evidence to show that opioids help control pain effectively beyond six weeks, Sullivan said.
“The sad truth is that, for a long time, doctors probably got more training about treating tuberculosis than they did about treating chronic pain, so for many, they learned on the job, and often the information they had was inaccurate, at best,” Sullivan said. “The higher the dose of opioid and the longer you’ve been on it, the more likely you become more sensitized to pain.”
Dr. Rahul Gupta, state health officer and commissioner for the Bureau for Public Health, said he was heartened by the CDC’s guidelines, especially in regard to questions concerning the relative safety of long-release opioid drugs.
“These long-release opioids may not obtain the benefits we originally thought — certainly, I was sold that way back when I was in practice full time, by pharmaceutical reps who say, ‘Use these, they’re not short-acting,’ ” Gupta said. “I think the guidelines do a good job by saying, ‘Do not start with extended-release or long-acting drugs,’ because they’ve haven’t proven their case over the years.”
Another important focus of the recommendations, Gupta said, is cautioning against using or prescribing opioids and benzodiazepines together. Benzodiazepines, a class of psychoactive drug commonly used to treat conditions like anxiety, insomnia and seizure disorders, can cause overdose when taken with other depressants, like opioids.
Earlier this year, Gupta joined other public health officials across the nation in signing a “black box” petition imploring the Food and Drug Administration to place warnings on opioid and benzo labels urging patients not to take them in combination.
“Along with the opioid overdoses and deaths, we’re seeing the concomitant use of both and increasing overdose deaths from benzos,” he said. “I think it was a very important step for the CDC to recognize that it should be avoided whenever possible.”
For Sullivan, the recommendations are an important first step in reversing attitudes about the necessity of using opioids to treat pain.
“They’re clear that very few people need opioids for chronic conditions,” he said. “Getting through this epidemic is going to be lots of baby steps, but this is a big one. Implementing it is going to be a challenge, but at least now we have this blueprint and we can move forward as a nation, as it applies in every state, and start to teach this in a more rational fashion.”
Reach Lydia Nuzum at firstname.lastname@example.org, 304-348-5189 or follow @lydianuzum on Twitter.