Overdose deaths in the U.S. are higher than they have ever been. In 2022, there were 109,680 overdose deaths, with both the death rate and the number of deaths at all-time highs. Most of those deaths involved opioids, with by far the most-involved opioid being fentanyl. And although the final fatal overdose for most individuals was not caused by a prescription they got from a health care provider, almost all of those who died became addicted in the first place from using a legally-issued narcotic prescription.
Because most opioid addiction starts with a prescription, the Centers for Disease Control and Prevention previously put out guidelines regarding opioid usage, and recently put out a significant update on its advice for opioid prescribing.
The CDC is earnest, well-intentioned and very large, and the recent guideline shares these same three characteristics. The guideline has 359 footnote references, 72 different authors, and is exactly 100 pages long in PDF format. What the guideline unfortunately does not have are any studies showing that chronic opioids make chronic pain significantly better. It also does not have even basic statistics of how many people are harmed vs. how many people are helped by the basic choice to use chronic opioids for chronic pain.
In brief, this is what the new CDC guidelines say:
Chronic pain is a terrible problem. So, even though opioids have some side effects, chronic opioids should still be used regularly if other treatments don’t resolve the pain because they are a vital part of the treatment of chronic pain. The main focus should be to treat people with compassion and equity as you give them opioids and to almost never take them off opioids because that will destabilize them and may likely injure them.
The following is what the CDC guidelines should have said if they were being accurate about the effects of chronic opioid use for chronic pain:
Chronic pain is a terrible problem, and there are clearly patients whose pain is not relieved by non-opioid treatments, but chronic opioids do not make chronic pain better — they make it worse. Once a patient has been on opioids for a while, the number of pain receptors in their body will upregulate, and it will become nearly impossible to safely get them back off because the withdrawal and pain are so horrible. In addition, for most patients, chronic opioids will eventually also cause serious new problems such as clouded thinking, constipation, terrible anxiety from opioid withdrawal, and the risk of overdose death. All of these bad things are the basic biological consequences of being on long-term opioids and will still harm people even if you treat all of them with compassion and equity. The opioid epidemic will never get fundamentally better until we maintain a prolonged focus on not trapping more patients on chronic opioids. For those who have already been made dependent on long-term opioids and then become unstable, medication-assisted treatment is vital so they can become stable — both with their pain and opioid use — so they don’t overdose and die.
The CDC guidelines recommend over and over that a prescriber should “carefully weigh the risks and benefits” of some action. They recommend it for starting opioids, for increasing the dose of opioids, for tapering opioids, and for adding or continuing other addicting sedatives together with opioids. On the one hand, “carefully weighing the risks and benefits” sounds very reassuring and wise, but on the other hand, in this context it is unhelpful to the point of being nonsensical. The benefits of starting or increasing an opioid dose are always the same: You can always make their pain better for the next few hours and the next few weeks. The risks are also always the same: A few months from now, the pain will be back just as bad or worse than it was before (even with ongoing use of a higher dose) and the risk for withdrawal and overdose death will be higher than it was before.
Think for a moment of a potential medicine that could be used to treat cancer patients but was known to have the following three properties:
- In the short term, it stops cancer.
- In the medium and long term, it will always make the cancer worse.
- Once your body is used to having it, if you try to stop it, it will make the cancer quickly much worse.
How many new patients with cancer would you start on this medicine? We wouldn’t consider this medicine for long-term cancer treatment. Now replace the word “cancer” with the word “pain” and you will have a good understanding of the “risks and benefits” of using opioids for chronic pain.
Much of the evidence cited by the CDC in support of its guideline relies on studies that show how poorly things go for patients when their opioids are taken away. But doing a study that shows that people do much worse when you take away the opioids on which they have become dependent is not the same thing as doing a study that proves that you made them better by starting them on the opioids in the first place. There are many convincing studies of the first thing, and none of the second thing.
Since we continue to suffer a huge and increasing number of overdose deaths from the use of opioids every year, it is so discouraging that the CDC would focus on suggestions for how to best continue using these damaging medications, with no acknowledgment at all of the lack of evidence for any long-term benefit. We should stop initiating more patients onto chronic opioids until we have at least one study that shows any net benefit, or failing that, it should be a high priority to commission some national randomized controlled trials to measure and quantify the benefits vs. harms of continuing to start new patients on chronic opioids.
Rep. Ray Ward, M.D.-Ph.D., represents Utah House District 19.