CDC Guideline appropriate for acute, not chornic pain

An Epiphany – March 2017 – by Lynn Webster, MD

Myra Christopher is the PAINS Director and someone I’m proud to call a friend. She has given me permission to re-post her blog, An Epiphany, here. It was first published at PainsProject.org

This morning I was a guest on Central Standard, a program which airs on the local Kansas City NPR station.  The program’s focus was chronic pain.  Over the weekend the host’s producer called to do a “pre-interview.”  One of the questions he asked me was about the relationship between efforts to improve chronic pain care and the opioid epidemic.

Although I am agnostic about opioids, on more than one occasion, I have been the victim of what a colleague calls “hit and run journalism” and alleged to be an “agent of big pharma” because of the position I take.  I think we have overused opioids.    

I do NOT believe they should be our first line of defense.  I think they are very dangerous medications; however, when prescribed and taken appropriately, they are safe and effective and can be lifesaving.  

In addition, I think we don’t know nearly enough about them.

Improper Treatment of Acute Pain Leads to Addiction

For at least five years, we have attempted to point out that there is clearly a correlation between efforts to improve chronic pain care which led to more liberal prescribing of opioids and the rise in abuse of and addiction to prescription pain medications.

However, even former CDC Director Tom Frieden, who spent much of his time post-Ebola crisis bringing the opioid crisis to the attention of the federal government and the American public, stated publicly that there is no known causal connection between these two public health issues.

Just as addictive as heroin.

One of the stated goals of PAINS’ newest initiative, No Longer Silent, is to clarify the relationship between opioid prescribing for chronic pain and the opioid epidemic – two critically important public health issues.

During my conversation with the radio producer, it struck me that the real “causal connection” here is the poor or improper treatment of acute pain.

Alternatives to Long-Term Opioid Prescriptions

Those of us who served on the IOM committee that produced Relieving Pain talked about the need to prevent chronic pain from occurring by providing better care for acute pain.  

However, the 360-page report gives little attention to prevention. In Chapter 2, Pain as a Public Health Problem, there are three pages focused on prevention. The section begins, “Perhaps the most important conclusion that can be drawn from a review of the enormous toll caused by pain relates to the need for prevention.  

A public health approach to prevention attends to the external, often structural, factors in the social and physical environments that affect not just individuals but populations.

These are the ‘upstream’ influences that shape conditions and behaviors that produce or exacerbate disease. In many instances, pain prevalence could be reduced as a consequence of normal public health initiatives aimed at preventing chronic disease….”

Upstream Influences

The CDC’s locus of concern about opioid prescribing for chronic pain, in my view, has been and continues to simply be misplaced.

It should be focused “upstream” on opioid prescribing for acute pain as a measure to prevent pain from transitioning from acute pain, a symptom associated with an injury, surgery, or disease, to a neurologic chronic disease!

After having this “Aha!!” I went back to the CDC Guideline for Opioid Prescribing for Chronic Pain and concluded that the real problem is they are mislabeled!  

Objections expressed by many individuals, including myself, and organizations about recommended limitations of dosage and duration of opioid prescriptions would dissipate if the Guideline was directed towards ACUTE, NOT CHRONIC pain.

What do you think?

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