Everyone knows the story of Goldilocks and her visit to the home of the three bears, where she was seeking the right balance between the things she discovers to attain the maximum comfort.
Medical professionals face something similar when it comes to prescribing opioids. We don’t want to prescribe too many pain killers, which may contribute to the epidemic of opioid misuse, yet we don’t want to have patients needlessly suffering who might benefit from opioids for pain management. Two recent publications highlight both the concerns regarding this issue and also the limitations in our knowledge regarding how best to achieve the ideal.
The first is a letter signed by over 300 medical professionals to the Centers for Disease Control and Prevention(CDC) regarding its guideline on prescribing opioids for chronic pain issued in 2016.1,2 The guideline strongly recommends limiting the use of opioids for the management of chronic pain, noting the lack of research to support their use for this and highlighting the potential benefits of using non-pharmacologic treatments and non-opioid medications.
Although the letter doesn’t dispute the CDC guideline recommendations, it expresses concerns that within a year of its publication, “there was evidence of widespread misapplication of some of the Guideline recommendations” including concerns about exceeding its recommended opioid daily dosage limitations.
According to the letter, the guideline has resulted in barriers to patients obtaining needed opioids including amount and dosage limitations set by insurance companies, limitations in dispensing the medications by pharmacies, and doctors themselves limiting or even refusing to prescribe opioids out of fear of legal action if they consider prescribing them in a manner that is different from what the guideline recommends. The letter also states:
Patients with chronic pain, who are stable and arguably benefiting from long-term opioids, face draconian and often involuntary rapid dose reductions. Furthermore, the guideline has created barriers that have resulted in not only unnecessary suffering because of patients being unable to obtain the opioids they require to control their pain but also other problems. In desperation, patients in pain are turning to suicide or illicit drug use or being forced to turn to invasive treatments such as spinal injections that often provide little benefit.
Dr King is in private practice in Philadelphia.
1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: US, 2016. MMWR. 2016;65:1-49.
2. Health Professionals for Patients in Pain. Professionals call on the CDC to address misapplication of its guideline on opioids for chronic pain through public clarification and impact evaluation. March 6, 2019. http://www.healthprofessionalsforpatientsinpain.org. Accessed May 12, 2019.
3. Sherry TB, Sabety A. Maestas N. Documented pain diagnoses in adults prescribed opioids: results from the National Ambulatory Medical Care Survey, 2006-2015. Ann Intern Med. 2018;169:892-894.
4. Darnall BD, Jurrlink D, Kerns RD, et al. International stakeholder community of pain experts and leaders call for an urgent action on forced opioid tapering. Pain Medicine. 2019;20:429-433.
5. National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder Saves Lives. Washington, DC: The National Academies Press; 2019.