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Recovery Changing the way opioids are prescribed New CDC guidelines are making a difference

Portsmouth Herald - 4/23/2017

PORTSMOUTH — In response to the ongoing opioid crisis, the Centers for Disease Control and Prevention has issued guidelines for physicians regarding their prescribing practices.

Dr. Gilbert Fanciullo, director of the section for pain at Dartmouth Hitchcock Medical Center, said he is grateful for the CDC guidelines and that the state of New Hampshire has become so involved and endorsed the guidelines.

“I believe this is helping physicians make better decisions,” Fanciullo said. “In our practice and nationally, I think fewer prescriptions are being written and I think we are doing a better job when it comes to educating ourselves and our patients about opioids.”

Managing pain is difficult. It is a subjective measure at best, and there is a move to remove pain as a quasi-vital sign. Still, patients do have pain, both chronic and acute and physicians want to help their patients be pain-free.

Opioids were routinely prescribed in the past to manage pain. However, doctors now recognize that that routine practice contributed to the current opioid crisis. The narcotics are highly addictive and pose a risk for patients with chronic pain. There is also an unintended risk because many people with a substance abuse disorder began their addiction by raiding the medicine cabinets of family and friends, and then moving to heroin when the prescription drugs became unavailable or too costly to acquire.

According to the CDC, an estimated 1 out 5 patients with non-cancer pain, or pain-related diagnoses were prescribed narcotics. From 1999 to 2015, more than 180,000 people died from overdoses related to prescription narcotics in the United States. In 2014, nearly 2 million people were dependent on opioids and, since 1999, sales of prescription opioids have quadrupled.

To help the country address these devastating numbers, the CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings.

Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than three months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

What the guideline is intended for is to encourages providers to implement best practices for responsible prescribing. It highlights the use of non-opioid therapies and advises doctors to start with low doses of opioids where appropriate, assessing from there. It advises prescribing fewer pills, to reduce the “leftovers” that exist in many people’s homes.

The guidelines also stress the need for patient education, and for the physicians to follow-up with the patients who are being prescribed narcotics.

“There are formulas we use when prescribing,” Fanciullo said. “Whether the drug is oxycodone, dilaudin or something else, the formula equates it a value of morphine. If we are prescribing the equivalent of 15 mg of morphine a day, the risk of death is higher.”

Fanciullo said there is no clear evidence that opioids are the best choice for addressing pain, and that, combined with the risk of death, it is common sense to be prudent with the use of the highly addictive drugs.

“I say that, keeping in mind who should be treated with opioids, and there are people for whom it is appropriate,” Fanciullo said. “The CDC guidelines help providers make better decisions., and to better understand the use and the ramifications.”

Fanciullo said the doctors at Dartmouth, and probably in most practices, have regular meetings. He said opioid use is a common topic among the collaborative discussions.

“We discuss the guidelines and what it means for us,” Fanciullo said. “All of our patients on opioids are required to have a urine toxicology test at least once a year, so we monitor them. We use the state prescription drug monitoring program for every case.”

The PDM provides prescribers, and pharmacists, a database to track if a person is “drug shopping,” seeking multiple prescriptions from different providers.

Part of the problem is that many patients, and even doctors, were not aware of the devastating impact opioids could have on society.

For his own patients, Fanciullo said it is not uncommon for him to discuss the risks of opioid use.

“Many choose now on their own not to take them,” Fanciullo said. “We discuss options and they are more likely now to try them first. Patient and provider awareness are changing."

One tough situation for pain doctors comes when they must treat a patient who already has a substance abuse disorder.

“It’s very tricky to treat an addict,” Fanciullo said. “Drug use changes the brain. Different parts of the brain light up during use, primarily in the brain’s pleasure center. This is a disease and as we begin to accept that more and more, we can begin treating it for what it is.”

Some people are prone to addiction. Fanciullo said others do not like the way they feel on opioids and they are less likely to face addiction.

“For the others, this feeling is among the best they ever had,” Fanciullo said. “So, they want more. It’s our responsibility to make sure there are less opioids floating around, and that we are being smarter about their use.”