CDC Guidelines on Narcotics: Generic Protocols vs Individualized Care
There is a narcotic epidemic in our country, with people dying of narcotic abuse some of which is due to prescribed pain medicines. As a consequence, the CDC published a detailed set of guidelines largely discouraging the use of narcotics for chronic pain. According to the CDC, prescription opioids are “really dangerous medications which carry the risk of addiction and death.” The CDC correctly asserts that there is a lack of data showing the benefit of long term narcotic use for chronic pain. However, what the organization does not state, is there also is not data showing that narcotics are ineffective for chronic pain. While the CDC states that patients with chronic pain should instead take medicines like Tylenol, anti-inflammatories, anti-seizure medicines, and non-drug treatments (acupuncture, exercise, massage, ect), many patients do in fact try those modalities before resorting to narcotics, and many others have no access to (financially and logistically) non-pharmacological treatments. The crucial question that the CDC does not address is the value and danger of long term narcotic use for chronic pain in each individual. Rather than relying on generic protocols to determine the appropriateness of medical interventions, it is important to know individual risks and benefits, something that the CDC does not attempt to do.
A recently published article by Dr. Steve Martin entitled: Neat, Plausible, and Wrong: A Response to the CDC Recommendations for Chronic Opioid Use, effectively demonstrates how the CDC guidelines are antithetical to shared decision making. It also helps us to ascertain actual risks and benefits of narcotic use compared to other more “preferred” pain treatments.
It is first important to realize that chronic pain is very dangerous. It has been shown to decrease life expectancy by 10 years; to increase the risk of depression and suicide; and to prevent people from exercising, working, and engaging in a meaningful life. While the CDC states that narcotics increase the risk of death, there is actually no good data to support that claim, especially since it is possible that narcotics can actually decrease the risk of death and disability if they alleviate chronic pain. While the CDC states that chronic narcotics have not been proven to help pain, there are many individual cases where in fact pain is improved with narcotics. Dr. Martin cites the conclusions of a 2014 NIH workshop that states: “Patients, providers, and advocates all agree that there is a subset of patients for whom opioids are an effective treatment method for their chronic pain, and that limiting or denying access to opioids for these patients can be harmful. [O]ur consensus was that management of chronic pain should be individualized and should be based on a comprehensive clinical assessment that is conducted with dignity and respect and without value judgments or stigmatization of the patient.” For each person to know if narcotics are appropriate, he/she must know the risks and benefits in real number terms.
The CDC discusses at length how addictive prescription pain medicines are in long term use. What is the risk of addiction with long term narcotic use, and how can that risk be individualized? In people with a past history of substance abuse and addiction, the rate can be as high as 100/1000. But, as the BRCT shows, in patients without substance abuse history, the risk of dependency and addiction is closer to 1/3000. Therefore, in talking to patients, it is important to understand their risk of addiction in ascertaining whether long term narcotics are safe.
The CDC also cites a high risk of death from narcotics. Again, most of this occurs in people with an addiction history or who have obtained the medicines illegally. The overall risk of death in narcotic use, as shown in the BRCT, is ½ to 2/1000, or approximately 1/1000. Again, this risk is higher in people who obtained the drugs illegally or who have an addiction history and are more likely to abuse them.
There are of course other risks of narcotics. Virtually all of them cause constipation, and in people who are frail or who have very poor balance they can cause an increased risk of falls and fractures. Most of the fracture risk occurs in the first 2 weeks of drug use. Compared to non-narcotic drugs in the frail elderly, there can be an increase of 100/1000 fractures with use of short term narcotics, and 30/1000 for long acting narcotics, as shown in the BRCT.
After the first two weeks of use, this risk is markedly smaller. Again, such a risk, which is sizable, must be individualized for each patient, as some are more prone to falls than others, and some will be able to take steps to reduce fall risk while others cannot. Like with falls narcotics are felt to cause memory and thinking problems, but in fact there is no good evidence that narcotics cause long term confusion or dementia, although there are some patients, especially those with dementia, who do get confused or agitated on these drugs. Given that pain itself can also trigger confusion and agitation in many people, this again is a balance that must be individualized for each patient.
The CDC suggests the use of Tylenol or anti-inflammatories such as Motrin instead of narcotics. But those medicines do not always work (studies suggest Tylenol is often no better than placebo), and they also have risks that have to be individualized. Anti-inflammatories are among the leading medicines causing people to be admitted to the hospital due to complications. Studies suggest that these drugs directly trigger 15,000 deaths a year, are responsible for 20% of all gastrointestinal bleeds, and lead to kidney damage in 2.5 million people. They also increase the risk of myocardial infarction, increase blood pressure, and cause people’s legs to swell. In fact, out of 1000 people who take anti-inflammatories, 3/1000 suffer major vascular events (such as strokes or heart attacks, as noted in the BRCT), 1/1000 die of such events, and 6-15/1000 suffer a gastrointestinal bleed.
Thus, like narcotics, anti-inflammatories must be individualized, as certain patients are likely to be more vulnerable to these side effects than others, and narcotics may be more appropriate for certain patients than would be anti-inflammatories.
In the end, while the CDC has demonized narcotics by broadly condemning their use and suggesting that other drugs and treatments are more appropriate, the truth is not quite so tidy. All drugs have risks and benefits that must be understood by those people who are going to take those drugs, and with that knowledge doctors and patients can find the interventions that are most appropriate for their own individual conditions and preferences. In a recent article America’s other drug problem, Kaiser Health News discusses the significant negative impact of many medications in the elderly, especially those who are hospitalized. In our book, and on this website, we have demonstrated the often small benefit and consequential risk of certain standardly prescribed drugs such as bisphosphonates for osteoporosis, statin cholesterol medicines, warfarin in atrial fibrillation, drugs to aggressively treat blood pressure and diabetes, and even aspirin for heart attack and stroke prevention. All medicines have risks and benefits that must be individualized as part of shared decision making between doctor and patient. To have generic protocols that dictate which drugs patients can and cannot use for pain negates the importance of using actual data to arrive at conclusions most appropriate for each person.