By Jacob Molyneux, senior editor
The CDC’s new Guideline for Prescribing Opioids for Chronic Pain was released this week. The context for this comprehensive new guideline is widespread concern about opioid-related overdose deaths and substance abuse in the U.S.
The guidelines make 12 main recommendations, among them the following:
- nonpharmacologic or nonopioid pharmacologic treatments should be considered “preferable” first-line therapy for those with chronic pain.
- a daily opioid dosage limit of morphine milligram equivalents should be imposed.
- immediate-release opioids should be prescribed before moving to extended-release formulations.
- urine testing should precede new opioid prescriptions for chronic pain and treatment goals should be set.
- clinicians should prescribe the lowest possible number of days’ worth of medication for acute pain (often three days or less).
- prescription drug monitoring program (PDMP) databases should be consulted to determine patients’ past histories of opioid prescriptions.
Some of the recommendations would seem to be no-brainers, such as consulting PDMPs when writing new prescriptions. Others, such as a “one-size-fits-all” daily dosage limit and restrictions on the use of extended release formulations, have raised alarms among pain management experts. See, for example, “I’m Worried About People in Pain,” a recent AJN Viewpoint essay by Carol Curtiss, a nurse and pain management expert, who notes the increased stigmatization experienced by pain patients and the chilling effects of new restrictions on doctors’ prescribing, to the extent that many are not prescribing opiates at all.
Along with more regular and efficient use of PDMPs, another step that can be taken by nurses and other clinicians is to educate patients about prevention of drug diversion. While drug overdose can potentially happen to anyone, a closer look at the available data reveals that a significant percentage of prescription opioid overdoses are among people taking drugs for which they do not have documented prescriptions. Renee Manworren provides practical steps to help nurses address drug diversion in a recent CE article, “Nurses’ Role in Preventing Prescription Opioid Diversion.”
Ethical quandaries often arise for clinicians in the treatment of pain. Nurse and ethicist Douglas Olsen addressed this thorny issue in our January issue through the use of hypothetical patient scenarios. As Olsen observed in “Ethical Practice with Patients in Pain“:
Responding to a patient’s pain is a fundamental ethical obligation in nursing. However, nurses caring for patients in pain can run into ethical conflicts from both over- and undertreatment of pain. Undertreatment of pain represents a failure to fulfill the core nursing obligation to alleviate suffering—but overtreatment may ultimately harm the patient, contradicting a core nursing value, nonmaleficence. The complex nature of pain complicates efforts to provide treatment that is ‘just right.’ Nurses must understand that complexity if they are to make ethical decisions in the care of patients who experience pain.
These new guidelines cast a very wide net. Many patients with chronic pain will find themselves facing new hurdles to adequate relief, as will clinicians who feel ethically bound to treat their patients’ pain while attempting to conform to new restrictions.
As one drills down into the available data, it emerges that a significant percentage of opioid overdoses occur in people who have exhibited signs of drug abuse. Many are using diverted prescription drugs or have, through “doctor shopping,” received five or more prescriptions for opioids from different doctors. In addition, a significant percentage of people with opioid abuse disorders in the U.S. have a documented mental illness. Other factors in play are socioeconomic, with regions of the country with high levels of poverty and inadequate access to drug treatment disproportionately affected by the opioid epidemic.
In an attempt to tell a compelling and “actionable” story about a very real set of problems and the efforts being made to address them, much of the coverage of these guidelines leaves out such context. But context matters. It’s crucial to reduce misuse of opiates while keeping them available to those who can truly benefit from them and can use them responsibly.