As government agencies, medical groups, hospitals, and pharmacies have tried to cut back on opioid prescriptions, they’ve wrestled with how to best do so. Should they restrict the number of days a prescription lasts? Should there be a cap on the total strength of the dose? What kind of exceptions should be made?

A new report issued Thursday by the National Academies of Sciences, Engineering, and Medicine outlines a framework for prescribers and others to develop their own plans for acute pain, without offering any direct recommendations itself. 

The report says any group drafting prescribing guidelines should consider a host of factors: the evidence, or lack thereof, for using opioids versus alternatives for a condition or procedure; the downstream effects of any prescription, such as refill requests and the possibility that some pills will go unused; and the broader potential implications of their plans, including pain relief and improved quality of life, as well as harmful consequences.

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It notes that the guidelines should not be seen as ironclad, and should allow for individual clinical decisions — a critical point at a time when many clinicians and others have argued that overly strict adherence to certain guidelines have harmed patients.

The committee also identified conditions and procedures for which prescribing guidelines should be developed or refined, including C-sections, wisdom tooth removal, low back pain, sickle cell disease, and migraines.

The Food and Drug Administration originally asked the National Academies to come up with a framework for developing evidence-based prescribing guidelines, but the committee that wrote the report took a broader approach, establishing a guidebook that any group can use.

“We realized that in addition to what the FDA might do, lots of other organizations are issuing guidance or positions for opioid prescribing,” said Dr. Bernard Lo, the president of the Greenwall Foundation and a former professor at the University of California, San Francisco, who led the committee.

The goal was to inject some consistency into a sometimes capricious approach. Depending on where they live or which hospital they go to or what kind of specialist they are treated by, patients can receive drastically different prescriptions for pain related to a condition or following a procedure.

Lo said that any group issuing guidelines should follow up with patients over time to make sure their pain was sufficiently addressed and that their quality of life was not hurt. Too often, he said, providers track only how a policy affects prescribing amounts. 

Although opioid prescribing has been trending down since 2012, the report found signs that overprescribing persists. After a surgery, between 41% and 72% of patients don’t finish their prescriptions, according to the report, and between 6% and 14% of patients remain on opioids six to 12 months after an initial prescription following a surgery or emergency department visit. If the underlying issue is addressed, acute pain should not last that long.

Some of the guidelines issued by states have also been difficult to interpret, Lo said, outlining the number of days an initial prescription can last without considering the specifics of a dose or a particular opioid medication.

The 15-member committee defined acute pain as sudden and lasting up to 90 days. Guidelines for acute pain are distinct from the debate about if and how to reduce opioid prescriptions for people with chronic pain, who may have been on the drugs for years.

Prescribing guidelines are meant to strike a balance so that doctors can properly treat their patients’ pain while reducing the chance that people take overly strong doses for too long — which can lead to addiction and overdose — and minimize the number of leftover pills stashed in medicine cabinets, which can be misused by friends or family members.

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  • Maybe there needs to be people who have taken the opioids for pain And then got off them need to be included in studies. Seems there are a lot of wrong people in some of the medical issues

  • I have nerve pain in feet hand and head plus ACDF at c spine 5and 6 .If I have to go back to that pain .I will exit this world .The world health organization stoke of this 2 years ago but Americans are blaming pain Patients

  • The system is too dysfunctional and corrupt to look at facts, and data before creating “guidelines.” The disaster we have now is due to industry corruption, misinformation and outright lies. No one considered any of the unintended consequences, as they ruined lives, caused deaths, and covered for various profit making schemes.
    People will continue to die, because profits are much more important than the lives of Americans. The so called Opioid Epidemic is an example of unregulated marketing, and a combination of market based approaches, that even as they led to more deaths, these “scientists” were silent. The approach looks genocidal.

    Now that most of the deaths are due to illegal street drugs, lack of meaningful treatment for the addicted, and willful ignorance, things are only getting worse. Blaming sick people and people in pain for an Epidemic Of Despair has not saved even one life.

    The so called opioid epidemic has been a marketing opportunity all along, and an opportunity to ruin the lives of patients, for a profit. We cant trust any of these self described experts, they have lied before and and mislead the public. The ongoing refusal to collect clear meaningful data or correct the lies and false narratives in the media and medical marketing will lead to even more deaths.
    No research was done on why people developed chronic pain, by design, to protect the healthcare industry. The statistics have to be collected in such a way to avoid pointing out the more obvious profiteering and mistakes in healthcare.

    If the US had a functioning healthcare system, like Medicare For All, we never would have had this problem. People would have has timely access to healthcare, when injured or when they became sick. They would not have been lied to by physicians as their conditions became intractable. Surgeons who sold implanted medical devices would have been caught and held accountable, before they ruined lives. It is too late now for the many Americans injured due to lack of ergonomic workplaces, and medical misadventure. As long as it is more profitable to cause long term chronic pain conditions and use this “crisis” to market dangerous fraud cures, medical implants that cause deaths, and to demean patients that report pain, we will see more suicides too.

    We are living in post fact America. These guidelines will be meaningless. We now have patients who will not have necessary surgeries, because they know their pain will not be treated. They continue to gas light all of us, as they protect the industries profit margins.

    If they can’t figure out how statistics work, or the difference between facts and marketing, it is highly unlikely the death rate will go down.

    It should be a crime to use inflated and misreported statistics health journalism/marketing. People die or suffer even more health problems, due to deceptive articles like this. Apparently that is profitable and that is all that matters here.

  • One must realize so no me inquires are permanent. It is possible to provide pain management techniques such as pain relief injections , oiad medicatns and hysica therapy to combat issues of quality of life living with pain. I had a pain management Dr. Tat recommended turmeric to help combatt my severe arthritis pain condition.

  • I lost my job at 52, due to 3 spinal surgeries, unending pain, acquired Fibromyalgia, with its many symptoms & Chronic Fatigue Syndrome. I was on low-dose Percocet for pain. The years of using acetaminophen, ibuprofen, and arthritis meds that are all NO LONGER AVAILABLE bcuz the damn things weren’t SAFE, caused me to develop Chronic Kidney Disease, from over use of NSAIDS. Tylenol is some of the worst crap for you to put in your body!
    So the Feds can stfu about how they have my best interests at heart by clamping down on the safest and only damn thing that helps my pain! I’ve got all those old pill bottles to prove that I was prescribed dangerous Cox-2 drugs for joint pain before I finally got a dr. who cared enough to put me on plain Oxy. It saved my kidneys & my job.
    Now I am cut down to half the original strength, which equals double the amount of hours of pain. So now I am adding in herbals- astaxanthin, a natural anti-inflammatory, others. Trying to figure out how to get relief from the constant joint & muscle pain. From spinal disks that are gone, or give sharp, knife pains at random times.
    Most of the pain drs that were in business are now running scared of the Feds. Who don’t care about us at all.
    I didn’t do anything to get this way! All I did was work for 34 yrs, in a factory, then office work. We are born with Fibromyalgia. The scoliosis came in my teens. The back pain began when I was 21. I’m 62 now. My savings are gone. Our dr appts run 2-6 per week! I have to drive now as hubby has Alzheimer’s. Our kids live in 3 different states. It is up to us to care for our selves & home. When I come home from dr’s appts, I have to go to bed to rest. Legs swell, back, neck, shoulders ache from driving, surgeries. He always did the driving, cuz it hurts me so. But now things have changed.
    My pain is increasing but the best pain meds are decreased! How do you care for a home, your self, bills, drs appts x2, and pets when your leg hurts from numb toes to throbbing knee & hip joints? Cooking? Nope. Can’t even stand the intense back pain to stand up to cook now. I fall due to the neuropathy in both of my feet. I don’t feel them- and I trip.
    We are the forgotten. The castoffs. If Germany had won in 1945, Hitler would have us on his list of those to go to gas chambers! We, through no fault of our own, have become “the useless eaters” of the 21st century. God Help America. God Help Us All.

    • This is absolutely horrible! My mother has cancer and can’t get anything for pain! I don’t understand who the fed are trying to help! And you’re right, Tylenol is horrible for any kind of pain. If anything, it should be banned! Tylenol alone kills thousands of people every year! Yet, you hear nothing about that!

  • I challenge the assertion that ” between 6% and 14% of patients remain on opioids six to 12 months after an initial prescription following a surgery or emergency department visit.” Two excellent large-scale studies contradict that assertion. Specifically

    A 2018 study reported in the British Medical Journal examined outcomes among more than 586,000 patients prescribed opioids for the first time after surgery. Less than 1% continued renewing their prescriptions longer than 13 weeks.

    Gabriel A Brat, Denis Agniel, Andrew Beam, Brian Yorkgitis, Mark Bicket, Mark Homer, Kathe P Fox, Daniel B Knecht, Cheryl N McMahill-Walraven, Nathan Palmer, Isaac Kohane, “Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study”, BMJ 2018;360:j5790
    http://www.bmj.com/content/360/bmj.j5790.long

    A 2016 study reported in the Journal of the American Medical Society tracked long-term opioid prescriptions in non-surgical patients, and compared prescription rates to 642,000 patients who received one of eleven common types of surgery. Opioid prescriptions were defined as “chronic” when 10 or more scripts were written in one year or a prescription was renewed continuously for more than 120 days.

    In this study, the rate for chronic prescriptions of opioid analgesics among millions of non-surgical patients was estimated at 0.136 percent. (Parenthetically, this finding strongly suggests that “doctor shopping” is not a significant source of opioids abused by people with addiction.) For 4 of the 11 surgical procedures studied, the same rate of prescriptions occurred after surgery as before. For the 7 remaining procedures, long-term opioid prescriptions rose by factors varying from 1.28 (0.174%) for caesarean delivery, up to 5.07 (0.69%) for total knee replacement.

    The highest rate of post-surgical chronic prescriptions occurred for total knee replacement – a procedure known to cause lingering pain in many who undergo it. It is likely that many on-going prescriptions after knee replacement reflected chronic post-surgical pain, rather than issues of opioid misuse. Although not examined in the study, this outcome may also be true of other procedures where long-term prescribing was observed.

    Eric C. Sun, Beth D. Darnall, Laurence C. Baker, Sean Mackey, “Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period”, JAMA Internal Medicine 2016;176(9):1286-1293.
    https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2532789

  • Says the person NOT in chronic pain, caused by years of nursing and taking care of others. Here’s some whining….i work, my last 5 discs are bone on bone….plus scoliosis. Chronic documented pain for 20yrs…and take away my medicine that made quality of life bearable.
    Walk a mile in someone else’s shoes before you judge people ok?
    This new law only gave the drug dealers better drugs to sell, that’s why the increase in OD’ s.
    I was told by my Dr., they could give me fentanyl, or oxy instead of norco….seriousy???? They want people to go to long acting extremely more potent meds, so there are less pills on the streets.
    I get their intentions, but look at chronic pain pts that do NOT want to go on disability, but work as long as they can walk…my quality of life is diminished! Why do I have to take continuing education credits of pain management, “pain, the 5th vital sign” every time I renew my nursing license, when because of someone who has never had to live in pain all the time, made the drug dealer laws for everyone required to take pain meds???
    It’s really ignorant to take productive people’s quality of life, so they will be in too much pain to work, and be forced to go on disability! Yep, really good problem solving.

    • People always think it’s such a tragedy when someone commits suicide. What’s tragic is that people have to live in pain so intense that they now have no other way to cope with it.

  • The article written by Andrew Joseph, which included information by Dr.Bernard Leo, is the best I have seen about the opiod prescribing problem. Unfortunately the people making decisions regarding this issue do not have the proper knowledge to benefit the public.I have reached out to Senator’s and Representatives to alert them about information I hold to help give answers on this subject. Unfortunately, as our President stated about Nancy Pelosi, she needs to pay attention to her constituants. Seems she is not the only elected offical who does not care about the people who put them in office.

    • I absolutely agree this is the first article I’ve seen that has any intelligence on the subject. What I want to see is well is the medical professionals not treating their patients like they are all addicts/seekers as this “war” has caused. Mine went so far as to elevate his voice at me saying it’s illegal to rx this for fibro! UNTRUE! Don’t give false info and don’t give us something that is specifically for an abuser/addict implying as such. One med made me horrid sick & so itchy so much so I have raw spots around trunk to heal from using a nail brush to scratch, & bad headaches (Tramadol) so not taking any more of it -, also my 12hr extended release med is being changed now, have yet to start it but this “Plan” is pushing some or most of us chronic pts backwards. Remember some or most of us have already tried all the CDC guidelines stuff ie antidepressants, muscle relaxers, epilepsy med, etc. which most times don’t work especially if not depressed, and make you feel really weird and detached and spaced out before we were finally placed on to an opioid med which helps a lot of us continue to work and stay off the ssi disabled payroll. It also pushes me backwards to again the too much tylenol and ibuprofen which i’ll have to now take for breakthrough. I was doing fine and complied with all but being subject to feel criminal because of this malady and what was working for many years and needing something stronger than over the counter I don’t know whats ahead now because we’ve gone back to them being afraid to prescribe anything due to the govts and states blaming & focusing the street addicts deaths on totally being a dr’s or pharmacists fault coz it can only come/start from them prescribing it in the first place which is ludicrous. They know where the crap is coming from on the streets, and never tell the whole story, and all this change against the chronic pain patients will not fix what is happening out on the streets. Never has, never will. The wrong people right now are suffering.

  • I’ve been bed ridden chair bound close to two years now waiting for whatever group forced tapered me at home alone 500+mme to 0 this 13+ year stable legacy chronic pain patient against CDC guidelines to come check on me. After all they force tapered someone who abided by the rules down to such a low dose it was completely ineffective then refused any other option making me have no choice but to suffer and stop all medication. Nobody saved me from addiction or overdose dont be fooled by smoke and mirrors rather they guaranteed myself and so many others a life of torture and pure misery not worth living until something changes or it ends. Please end this war on the innocent pain patients good good on the unnecessary harm you’ve caused us and then do us all a favor and go after the real problem instead of being part of it!

    • I was on opioids since age 35 due to post polio syndrome. I was a nurse for 36 years. Iowa has one of worst. Medical cannabis programs in the states. Post polio syndrome causes severe chronic pain and a new weakening muscles. I was falling more. Doctors are refusing to sign a form that states they have treated u for the diagnosis that would allow you to receive medical cannabis. Finally I had a severe fall with head shoulder and elbows injures. I went to my doctor and and told her she was slowly killing me. Against policy she signed my form. Medical cannabis as changed my life. I’m orient and oriented- I’ve woke up and I’m back to me again. Iowa has such low limits that I need 3 pills a day. I’m on disability with a small pension . I can barely afford it .it costs 300.00 for daytime control. A good medical cannabis program which would control pain make u relaxed and help u sleep. Iowa physicians pharmacist maybe people in the senate and maybe our governor are making millions off the suffering of Iowans .our fall rate for people over 65 that leads to death is #7 in the state. Start advocating for medical cannabis!!!!! Being on benzodiazepines and opioids will slowly kill you or u will decline faster. Anyone on benzodiazepines and opioids can feel so great . With medical cannabis now available. I’ll be advocating loudly in iowa. The Sick and elderly and being pharmaceutical abused due to greed of our own caretakers and the state.

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