Beyond Opioids: New guidelines offer safest ways to control pain
By Cleveland Clinic’s Chronic Conditions Team
In the past, if you had minor surgery or an injury your doctor would often prescribe an opioid pain killer to ease your discomfort. But, that is less likely under new guidelines for physicians.
The Centers for Disease Control and Prevention (CDC) recently released the first federal opioid prescription guidelines. They are written for primary care providers, but patients should know about them, too, says pain management specialist Richard Rosenquist, M.D.
“The goal is to help physicians prescribe opioids in a rational fashion,” he says. “We have an incredible number of people dying from overdoses, and prescriptions must be more aligned with the medication’s proper use.”
The CDC’s guideline process highlights U.S. opioid abuse epidemic
An article in the Journal of the American Medical Association on the guidelines says more than 165,000 people died from opioid overdoses between 1999 and 2014. In 2013, roughly 1.9 million people abused their prescriptions.
Another startling statistic: Overall, the United States — which makes up about 5 percent of the world’s population — uses 80 percent of all prescription opioids.
And, opioids are often over-prescribed, Rosenquist says. Doctors either write prescriptions for too many pills or they offer opioids when there are better choices. The new guidelines, he says, will help them identify how and when a patient really needs an opioid.
A considered approach to managing pain
Here are changes you may see in your doctor’s approach. According to the CDC’s suggestions for managing pain, your doctor should:
–Look for non-opioid therapy options first. He or she should think about an opioid to treat chronic pain only when benefits outweigh risks.
–Work with you to create a plan to treat your pain. The plan should set realistic goals and focus on limiting opioid use. You and your doctor should also discuss how you will stop taking the drugs when the time comes.
–Talk to you about the risks and benefits of controlling pain with opioids. You should discuss this before you first take them and, over time, for as long as you take them.
–Try immediate-release opioids first. He or she should opt for extended-release drugs only if immediate-release opioids don’t work.
–Start low; go slow. He or she should take care to start your therapy with the lowest dose necessary, and increase the dose slowly — and only if needed.
–Limit your opioid therapy for acute pain to less than three days. Prescribing opioids for more than seven days should typically be rare. (Long-term use and abuse often begin with doctors treating pain from an injury or surgery.)
–Review how therapy is going. Your doctor should meet with you within one to four weeks of starting therapy for chronic pain to review how it is helping or hurting you.
–Use strategies to reduce risks. He or she should focus on your history and risk factors.
–Review your controlled-substance history every three months. Your doctor should check to make sure you are using prescribed drugs safely.
–Give you a urine test before prescribing opioids. This will help him or her double check on what prescribed drugs and other substances you use.
–Avoid prescribing opioids and benzodiazepines (tranquilizers) at the same time, if possible. Using them at the same time puts patients at greater risk for a potentially fatal overdose.
–Offer assisted treatments for patients with a history of abuse or dependence problems. The CDC suggests using drugs like methadone along with behavior therapy as an alternative.
Opioid side effects you should know about
Rosenquist says, opioids can help control pain, but higher doses do not necessarily make them work better. And, opioid use has serious risks.
If you take them long-term, they sometimes cause:
–Slower gastrointestinal function
–Decreased endocrine function
–Nervous system inflammation
–Greater response to less pain
Large daily doses of opioids — 200 mg morphine equivalents or — may put your risk of death at 1-in-32, Rosenquist says.
Combining opioids with a drug such as Valium boosts your risk of death between four and 10 times.
Ultimately, Rosenquist says, the guidelines should help doctors use opioids in a more rational and appropriate way and help head off problems before they start.
“People have begun to turn the faucet back on the availability of opioids,” he says. “The goal is not to eliminate their use altogether, but rather to use them in a more effective fashion and to reduce the incidence of prescription drug abuse and death.”
(A Wellness Update is a magazine devoted to up-to-the minute information on health issues from physicians, major hospitals and clinics, universities and health care agencies across the U.S. Online at www.awellnessupdate.com.)
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