On a Sunday morning in the spring of 2016, shortly after the Centers for Disease Control and Prevention (CDC) issued its first “guidelines” for safely prescribing opioid pain medications, I was cooking breakfast when I burnt my finger on some very hot oil. While I was experiencing pain even after applying lots of ice, my biggest concern was infection.
My husband drove me to the nearest urgent care, and along with a strong topical antibiotic, I left the clinic with a prescription for a 30-day supply of oxycodone. The next day the pain was gone. I never filled the opioid prescription.
I was working in addiction research at the National Institutes of Health (NIH) at the time, and very aware of how the prescribing of opioids for pain management was tied to the growing epidemic of misuse and overdose deaths. I wondered how long it would take for the new CDC guidelines to get out to doctors, hospitals, and clinics.
But we could not have imagined the complex web of unintended consequences that would be unleashed by those guidelines.
Over the years, the use of these medications skyrocketed. There were 68,630 opioid-related deaths in the U.S. in 2020 alone, according to the National Center for Health Statistics. It was this spike and others that had been happening over years that resulted in 39 states passing laws imposing severe penalties (including loss of medical license) for not strictly following the CDC guidelines.
Doctors became afraid, and many began to taper patients’ doses. Some refused to treat chronic pain patients with opioids, even in cases where the patients had been on them for an extended period and changing to a different analgesic would no longer be effective. While the guidelines did not call for such draconian measures (they called for individual care planning including counseling and close patient monitoring) doctors took drastic action to avoid the liability.
Tragically, many patients with severe chronic pain who could no longer get the drugs that had been effectively helping them for years, turned to unsafe illicit drugs or committed suicide.
An additional consequence is unfolding where physicians are retiring and pain clinics are closing down, and patients cannot find new practitioners willing to continue their effective treatments, as pointed out in a recent edition of the New England Journal of Medicine.[1]
The original overprescribing of opioids for pain came at a time when primary care doctors were taught very little about addiction, its identification, prevention, and treatment. Most physicians had little to no experience during internships and residencies with people suffering from it, and were not trained adequately in pain management. It did not help that there was a belief among many that opioids used for treatment of pain would not increase risk for addiction (a relic from a few small retrospective studies published in the 1980s).
Once cases of addiction began increasing, doctors were at a loss for what to do. Now, there is a growing movement by medical schools to address more about pain and addiction, especially in the case of opioids. Interestingly, this is coming at the insistence of medical students who have witnessed these problems firsthand with friends and family.
Today these consequences have led the CDC to reexamine the guidelines and new ones will be published later this year. Scientific advances made in our understanding of pain treatment and addiction should be prioritized in its revisions.
Developing evidence-based guidelines that are rooted in strong scientific data and recognize the practical realities of medical training and practice will lead to the most effective patient-centered care, while implementing the difficult lessons learned from the past.
[1] Coffin and Barreveld; N Engl J Med 2022;386:611-613