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Beyond CDC Guidelines for Opioid Prescribing: What’s Next?
It was billed as a compassionate approach to pain. Instead, the aggressive prescribing of opioid painkillers such as OxyContin, Percocet and Vicodin became the driver of an addiction epidemic that has caused overdose deaths to more than double since 2002.
So there’s much to praise in new prescribing guidelines released recently by the Centers for Disease Control and Prevention (CDC) that seek to change that narrative. Most notably, the guidelines encourage doctors to use non-opioid drugs wherever possible and to limit any opioid painkillers they do prescribe to low doses and less than a one-week supply. Many experts believe doctors will embrace the recommendations and the results will be transformative, helping to prevent new opioid addictions from taking hold.
Equally important, the guidelines don’t overlook those already struggling with an opioid use disorder. For these patients, doctors are urged to offer or arrange evidence-based care. That includes medication-assisted treatments such as buprenorphine, methadone and extended-release naltrexone (Vivitrol).
Those of us who treat opioid-dependent patients hope this recommendation is met with the same adherence as the prescribing limits. While reining in the prescribing of opioids is a positive step, it is not a magic bullet. In fact, limiting pain pills isn’t without risks. In some instances, it simply moves the problem from abusing prescription pain pills to abusing that other opioid — heroin. A 2012 study in The New England Journal of Medicine concluded, for example, that reformulating OxyContin did indeed decrease the number of people misusing it, but it “generated an unanticipated outcome: replacement of the abuse-deterrent formulation with alternative opioid medications and heroin, a drug that may pose a much greater overall risk to public health than OxyContin.”
Thus, while the CDC prescribing limits are an important step in stemming the growing tide of use, the war against opioid addiction needs to be waged on multiple fronts. We cannot overlook treatment and prevention of relapse.
The new guidelines go into effect immediately, but it will take time to see the full impact of the changes. Unfortunately, this doesn’t solve the current crisis of overdose deaths. For that, we need to focus on getting people into treatment. So far, our record isn’t good. According to the Substance Abuse and Mental Health Services Administration, 21.2 million Americans ages 12 and older reported that they needed treatment for a drug or alcohol use problem in 2014, but only about 2.5 million people received it. Meanwhile, more than 40 Americans die each day from prescription opioid overdoses alone.
Opioid addiction is a disease that responds best to a combination of behavioral therapies and medical attention, and that can include pharmaceuticals such as buprenorphine, methadone and naltrexone. I find a newer option, Vivitrol, an injectable form of naltrexone, to be particularly advantageous. Vivitrol is the only once-monthly, non-addictive, non-narcotic FDA-approved medication to prevent relapse to opioid dependence. Unlike replacement therapies such as methadone and Suboxone, Vivitrol works by blocking certain brain receptors related to euphoria. That means the patient cannot experience a high while on it. And its once-monthly dosing helps patients adhere to their treatment plan rather than having to take a daily medication. That said, all of the medication-assisted treatments are viable options, and the public needs to be aware that they exist and are effective.
There is no question that there needs to be more judicious prescribing of opioid painkillers. But for the millions of Americans who are already in the throes of addiction thanks to the practices of the past, focusing on prevention is not enough. We need to embrace all aspects of the new CDC guidelines and improve access to and support for effective treatment of the disease.