The Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain have become a model for physicians to follow when prescribing an opioid for the first time, as well as to evaluate the risks and benefits of long-term opioid use (greater than 3 months).
To help you better understand how the CDC's recommendations will affect you, Practical Pain Management spoke with Forest Tennant, MD, DrPH.
Q: When your doctor says he or she wants to evaluate your function what does that mean?
Dr. Tennant: The CDC guideline states "clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patients.” Most people don't understand what is meant by the term "function". Function refers to the activities of daily living, which include using the bathroom, personal hygiene, sleep, getting in and out of bed, eating, etc. Function can also mean improving your quality of life. Does pain interfere with your routine? If so, how? Can you drive yourself to the grocery store? Walk the dog for 10 minutes? Play with the grandchildren?
The aim of pain management is to reduce (not eliminate) your pain so that you can perform ordinary, daily tasks. Effective pain management should enable you the ability to participate in your life. It does not benefit you if your pain management treatment leaves you feeling zonked out or incapable of getting off the couch.
Q: Many patients wonder why they are being asked to take a drug test if they are not drug addicts. Can you explain?
Dr.Tennant: The honest answer is that because of the increase in abuse and diversion of opioids, including people who sell their medication, everybody who is prescribed a controlled medication now has to be tested.
The CDC guidelines recommend “before starting, and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms.” This includes taking a patient’s history of controlled substance prescriptions and the use of urine drug testing. The drug test either will confirm that a patient is taking a medication as prescribed, or alert the physician that the medication is not being taken or taken with another illicit drug, such as marijuana or heroin.
By performing a drug test, we are not accusing patients of anything. This is just standard procedure now.
Q: There have been anecdotal reports of physicians cutting back on a patient’s opioid prescription because of the CDC guideline. Is there ever a time when an opioid prescription would be reduced?
Dr. Tennant: If a patient is stabilized and doing well, there is no medical reason to take them off or change their opioid regimen. In fact, the CDC guideline never recommends cutting back or weaning opioid medications if the patient is functioning well. The only reason to adjust a medication is if the patient is no longer receiving a benefit (less pain; increased function) from that medication. Then the physician should re-evaluate the patient: Have they increased their activity level? Sometimes when someone is feeling better, the person can start to move more, which can lead to an initial increase in pain. Have they become house-bound and/or bed-ridden? Have they showed signs of developing an opioid use disorder or potential addiction?
Unfortunately, the main reason why patients are being taking off opioids are non-medical: insurance will no longer pay for the prescription; the family wants them off the medication; or the physician is no longer comfortable prescribing opioids.
Medical reasons for decreasing an opioid dosage would include opioid-induced constipation, hormone depression (low testosterone or low pregnenolone), or signs that the medication is no longer working (increase in pain or decrease in function).
Q: Should opioids ever be abruptly halted?
Dr. Tennant: No. Abruptly stopping opioids would not only put the patient at risk of developing withdrawal symptoms, but could also trigger a pain flare. That is why we recommend a slow weaning of the medication over weeks, not days. Ideally, as the opioid is slowly being removed, the physician will be introducing a non-opioid pain medication to manage the pain.
Read more in our "Is it Addiction or Physical Dependence" overview with Dr. J. Kimber Rotchford.
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