What the CDC's Opioid Prescribing Guidelines Mean for Primary Care Physicians

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Erin E. Krebs, MD, MPH, from the Women's Health Medical Director at the Minneapolis VA Health Care System.
Erin E. Krebs, MD, MPH, from the Women's Health Medical Director at the Minneapolis VA Health Care System.

PALM SPRINGS, Calif. — The Center for Disease Control and Prevention (CDC)'s proposed guidelines for prescribing opioids in patients with chronic pain have sparked backlash from some advocacy groups claiming to support the needs of patients in pain. They believe the agency's proposed draft ties the hands of clinicians, thereby preventing practitioners from being able to effectively treat their patients. Others in the medical community disagree and recommend that the CDC's guidelines "represent the best current knowledge about how to use opioids effectively for chronic pain."

Clinical Pain Advisor met up with Erin E. Krebs, MD, MPH, at AAPM's annual meeting after her discussion on what opioids mean for the primary care physician in 2016 to get her perspective on the topic. 

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She is the Women's Health medical director at the Minneapolis VA Health Care System and the core investigator at the Minneapolis VA Center for Chronic Disease Outcomes Research. Dr Krebs is also the associate professor of Medicine at the University of Minnesota.

Clinical Pain Advisor: What does the CDC's Guideline for Prescribing Opioids for Chronic Pain aim to address?

Dr Erin Krebs: The intended audience is primary care providers and the focus is on opioid prescribing for adult patients with chronic pain. The recommendations apply to management of common problems such as back pain and arthritis pain. They do not address pain management in patients being treated for life-threatening disease, such as cancer, or in patients at the end of life.

CPA: How can the guidelines go further when it comes to preventing opioid abuse, misuse and overdose?

Dr Krebs: The guidelines focus on improving opioid prescribing for chronic pain and do not address prevention of opioid abuse outside of that context. Other public health approaches are needed to reduce prescription opioid abuse more broadly.

CPA: What would you say to patients with pain who oppose the CDC's proposed guidelines?

Dr Krebs: I would assure them that the guidelines do not recommend a one-size-fits-all approach to opioid prescribing. The guidelines recommend individualized care based on careful assessment of response to opioids and risk for harm. They encourage primary care providers to work with patients to understand their pain and personal goals for treatment, to use a variety of pain management approaches, and to prescribe the lowest effective dose of opioids.

CPA: Who is to blame for the country's opioid epidemic?

Dr Krebs: There is plenty of blame to go around. We know from legal proceedings that some pharmaceutical industry executives were guilty of deceptive promotion practices, but that is far from the whole story. 

I think research funding agencies should accept some responsibility for not sufficiently prioritizing pain research. If you look, for example, at the public health burden of chronic back pain compared with the amount of NIH funding for back pain research, you will see a huge disconnect. 

Similarly, medical schools and physician training programs are not devoting nearly enough space in the curriculum to pain management. I also think the health care industry should accept responsibility for investing in a "too good to be true" answer to the complex problem of chronic pain.

Lack of access to other pain treatments is part of the reason for opioid over-prescribing. We have evidence-based treatments for pain — mostly low tech, high touch treatments — that most people with chronic pain can't access. 

Finally, we health care providers should accept responsibility for being overly optimistic about opioids' potential to treat all kinds of pain. Given the lack of good scientific evidence, most of us were insufficiently skeptical of broad claims for opioid effectiveness and safety.

CPA: How can opioids be used effectively in patients with chronic pain?

Dr Krebs: Fundamentally, if we want answers to the critical questions about opioids in particular and chronic pain management in general, we need more funding for pain research. In the meantime, I think the CDC guideline recommendations represent the best current knowledge about how to use opioids effectively for chronic pain. We also need to put opioids in their place. 

Opioids are only one treatment for pain and probably not the best treatment for most people with chronic pain. If we can ensure all patients with chronic pain are getting optimal non-opioid pain care, our use of opioids will be more targeted and more effective. 

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