New Centers for Disease Control Guidelines on Opioid Prescriptions

At the Law Offices of Joe Miller Esq. and the Work Injury Center, we are very aware of the expanded use of opioids to treat work injury pain and other pain causes. As part of our continuing effort to keep informed and keep our clients and working partners informed, we are writing to advise of the latest guidelines developed by the Centers for Disease Control in Atlanta (CDC) for prescribing opioid medications. We have previously written about the new Virginia Laws on prescribing Opioids, which pretty much track the previously enacted CDC rules.

As we have reported previously, while we certainly support law enforcement and any and all efforts to curb this horrific national epidemic of opioid deaths, we are concerned that the passing of these laws and guidelines in response primarily to the actions of criminals and thugs will adversely affect our law-abiding injured worker clients. Many of our clients have suffered extremely serious injuries and opioids are often the best and only way to substantially decrease their pain after major surgeries or surgery failures.

The Centers for Disease Control in 2016 developed new guidelines in response to the opioid prescription crisis. Opioids are chemicals that work on nerves in the brain or the body to reduce the severity of pain. They are either derived directly from the seed pods of the poppy flower papaver somniferum , which is also used to make heroin, morphine and opium, or from synthesized derivatives of the plant or synthesized chemicals.

Sadly, many people are becoming addicted, overdosing, or abusing their prescriptions. The guidelines are specifically aimed at helping primary care doctors known when to prescribe the drugs and when and how to monitor their patients. The guidelines apply to patients who have pain that lasts three months or more. The guidelines do not apply to patients who take the opioids for cancer treatment, end-of-life care, or palliative care.

According to the CDC, opioid prescription use has quadrupled since 1999. Over 183,000 people have died due to their use or misuse of opioid prescriptions since that year. The recommendations are designed to provide standard current guidelines for clinical practices. Specifically, the guidelines target the choice of opioids that are prescribed, the proper dosage, how long the drugs should be used, what sort of follow-up doctors should do, and when the prescriptions should terminate.

The full guidelines can be seen here – Guidelines for Prescribing Opioids for Chronic Pain

The purpose of the guidelines

The purpose is help physicians make recommendations when they treat chronic pain. They are a “best practices” set of standards for responsible prescribing.

Non-opioid remedies are suggested such as exercise and cognitive behavior therapy. Non-opioid drugs such as anti-inflammatories are encouraged. The guidelines state the opioids should not be the routine recommendation. Even when opioids are prescribed, the doctor should combine their use with the other non-drug therapies for maximum benefit.

Doctors are advised to prescribe the lowest possible effective drug dosage and begin the treatment by using immediate-releasing opioids instead of opioids that are extended-release or long-acting. Opioid prescriptions should only be for the time needed to manage the pain duration.

Providers should follow-up with their patients by scheduling regular appointments to see if the benefits of the opioid prescription are causing their patient harm and whether their patients are applying the non-pharmacological treatments that are available.

What’s included in the guideline?

More specifically, the guidelines focus on the following three assessment areas:

• When the doctors should start and when they should continue the prescription of opioids for chronic pain. This includes the selection of non-drug therapies, non-opioid drug therapies, and opioid therapies. The goals of the chronic pain treatment should be established and the doctors and health providers should discuss the pros and cons of the therapies with their patients.
• Doctors should understand the full scope of opioid medication treatment. The guidelines cover which opioid medications should be used, what dosages should be prescribed, how long the treatment should be, and there should be a plan for when the opioid prescriptions will be discontinued
• The health providers should understand the specific ways opioids can harm the patient and what ways there are to minimize the risks. The doctors should review prescription drug monitoring program (PDMP) data. There should be urine testing to examine how much drugs are in the patient’s systems. The guidelines do mention that the doctor should consider what could happen if benzodiazepines are co-prescribed. If the patient develops an opioid use disorder, there should be a plan in place to respond to that disorder.

How do the 2016 CDC opioid prescription guidelines differ from prior guidelines?

There are several key differences:

• Different dosage recommendations. The new dosage recommendations are lower. The higher the dosage, the greater the risk the patient may overdose and die. Even low dosages, the CDC recognizes, the equivalent of 20-50 milligrams of morphine pose increased dangers.
• The prior guidelines focused on just high-risk patients. The new guidelines recognize that all opioid use patients are at risk of abuse or harm. In addition to their own monitoring programs, physicians are encouraged to use state prescription drug monitoring programs (PDMPs) which have the latest technological advances.
• The 2016 guidelines have more detailed suggestions, compared to prior guidelines, for monitoring the patient use of opioids and for terminating the opioid prescriptions when the potential dangers are more than the benefits.

Additional Centers for Disease Control activities to address the opioid crisis

In addition to offering new guidelines, the CDC is attempting to help people suffer less from opioid abuse and helping families not have to bury a loved one who overdoses in the following ways:

1. Enhancing and maximizing the use of prescription drug monitoring programs (PDMPs). These programs are databases run by the states to track the prescribing and dispensing of controlled prescription drugs to patients. The PDMPs are set up to help detect when there is abuse of opioid prescriptions such as for illegal use. The database helps the doctor doing the prescribing and the pharmacist understand the patient’s substance prescription history. In this way, your doctor and the pharmacy can see which patients are high-risk and need more aggressive intervention.
2. Helping the states create better programs though the Prevention for States program. The Prevention for States program helps states address opioid overdoses by providing the state the resources and support they need for more advanced intervention. The CDC chose 16 states to begin participation in the program starting in September 2015 to develop strategies for the safe prescription of opioids and the best way to handle abuse, misuse and overdoses. An additional 13 states, for a total of 29, were added in March of 2016. The 29 approved states include North Carolina and Virginia. The CDC plans to give each state up to $1 million to help advance prevention in four main areas:
   • Maximizing the PDMP through universal registration, making the databases easier to use and access, making the date more timely, expanding the identification and reporting of suspected abuses – all with the aim of getting a better understanding of the opioid overdose epidemic.
   • Community or Insurer/Health Systems Interventions which give technical help to counties and communities that have a high-amount of opioid abuse, improving opioid prescribing interventions for insurers and health systems, and enhancing the use of the guidelines
   • Evaluating the interventions to better understand what helps and what does not
   • A rapid response project to advance prevention of abuse.

The Prevention for States program evaluates how the state’s activities are working including focusing on relevant success stories. How well the program does will determine future national and state efforts.

3. Some of the strategies that have been developed or are being explored – for combatting the opioid crisis at the state level are:

• Finding ways to increase the use of the drug monitoring programs
• Finding ways to help pain clinics reduce the over-prescription of opioids to patients with a risk factor of abuse or problems using opioids
• Evaluating the data to find ways to “assess Medicaid, workers’ compensation programs, and state-run health plans to detect and address inappropriate prescribing of opioid pain relievers, such as through use of prior authorization, drug utilization review, and patient review and restriction programs.”
• Increasing the ability to access treatment services for substance abuse including Medication-Assisted Treatment (MAT)
• Identifying ways to expand first responder access to naloxone, aka narcan, a drug used to reverse overdose.

4.  The CDC is also working to have the states promote the use of the new 2016 CDC guidelines on Prescribing Opioids for Chronic Pain and in putting strong practices to work in the neighborhoods where drug addiction is the norm. The CDC is also working to develop and implement rapid response plans.
5.  Improving the way data is tracked and used to help monitor the crisis

Categories of opioids

The CDC examines these four types of opioids:

1. Natural opioid analgesics, including morphine and codeine, and semi-synthetic opioid analgesics, including drugs such as oxycodone (Percocet), hydrocodone (Vicodin or Narco), hydromorphone, and oxymorphone;
2. Methadone, a synthetic opioid;
3. Synthetic opioid analgesics other than methadone, including drugs such as and fentanyl; and
4. Heroin, an illicit (illegally-made) opioid synthesized from morphine that can be a white or brown powder, or a black sticky substance from the poppy plant papaver somniferum.

Opioid analgesics (commonly referred to as prescription opioids) have been used to treat moderate to severe pain in some patients. Natural opioids, semi-synthetic opioids, methadone (a synthetic opioid), and some other synthetic opioids are commonly available by prescription.

Fentanyl is a synthetic opioid that is legally made as a pharmaceutical drug to treat severe pain, or illegally made as a non-prescription drug and is increasingly used to intensify the effects (or “high”) of other drugs, such as heroin.

Why the opioid epidemic is growing

Opioid deaths are rising across most every demographic including men, women, all races, and most ages. Over 60% of drug overdose deaths now involve an opioid. Some of the data statistics for opioid use are as follows:

According to the CDC, in 2015 there were nearly 62 deaths each day due to opioid abuse – over 22,000 for the year. This was a increase of 3000 over the number of prescription opioid deaths in 2014. A good part of the increase was due to the use of synthetic opioids other than methadone. One of the leading synthetic opioids that concerns law enforcement and is believed to be causing the increase in deaths is illegally-made or obtained fentanyl or carfentanyl. Carfentanyl has been previously described as a weapon of mass destruction and chemical weapon and is 10,000 times more powerful than morphine and 100 times more potent than fentanyl. The DEA issued a dire warning to the public regarding carfentanyl in 2016. Even casual contact with a small amount of the drug can cause sickness and death.

It can be hard to determine the exact cause of opioid deaths because the data doesn’t distinguish between legally and illegally-made fentanyl. The CDC is trying to address this disparity.

Between 1999 and 2014:

• The 25-54 age range saw the highest rates of overdose deaths
• Non-Hispanic whites, American Indians, and Alaskan Natives had higher rates of overdose deaths than non-Hispanic blacks and Hispanics.
• While men suffer more deaths from opioid deaths than woman, the gap is closing.

In about 20% of drug overdose fatalities, the death certificate does not list the specific drug that caused the death. Adding to the problem of determining which drugs caused an overdose death is that often multiple drugs (such as a prescription opioid and heroin) are found in the patient.

Prescription opioids are involved in more overdose drug fatalities than any other drug. It is believed that the proportion of deaths cause by prescription opioid use is actually higher than is being reported. Two of the reasons for the increase in opioid overdose deaths are believed to be:

1. A 15-year increase in deaths from prescription opioid overdoses
2. Illegal opioid overdoses of which heroin and fentanyl are the leading drivers. Other leaders are methadone, Oxycodone (such as OxyContin®) and Hydrocodone (such as Vicodin®)

Other risks from opioid use besides overdose deaths are abuse, addiction, and abuse

• Nearly 2 million Americans either abused or were dependent on prescription opioids in 2014.
• Nearly 25% of Americans who get prescription opioids for long-term non-cancer pain in primary care settings struggle with addiction.

The prescription opioid epidemic affects more than 1,000 people each day.

Speak with an experienced North Carolina and Virginia workers’ compensation attorney today about opioid abuse
Attorney Joe Miller Esq. has been helping injured workers for over 25 years. He has helped thousands of employees get just recoveries. Part of his work as a workers’ compensation lawyer is helping clients work with skilled medical professionals to get the medical attention and care that is required. To learn more about your work injuries and the issues in treating them, please call (888) 694-1671 or fill out our contact form.