Prescription painkillers should not be a first choice for treating common ailments like back pain and arthritis, according to new federal guidelines designed to reshape how doctors prescribe drugs like OxyContin and Vicodin.
Amid an epidemic of addiction and abuse tied to these powerful opioids drugs, the Centers for Disease Control and Prevention is urging primary care doctors to try physical therapy, exercise and over-the-counter pain medications before turning to painkillers for chronic pain. Opioid drugs include medications like morphine and oxycodone as well as illegal narcotics like heroin.
The new recommendations—which doctors do not have to follow—represent an effort to reverse nearly two decades of rising painkiller use, which public health officials blame for a more than four-fold increase in overdose deaths tied to the drugs. In 2014, U.S. doctors wrote nearly 200 million prescriptions for opioid painkillers, while deaths linked to the drugs climbed to roughly 19,000—the highest number on record.
"We're trying to chart a safer and more effective course for dealing with chronic pain," Dr. Tom Frieden, the CDC's director, said in an interview with the Associated Press. "The risks of addiction and death are very well documented for these medications."
More than 40 Americans die every day from painkiller overdoses, a staggering rate that Frieden said is "doctor driven."
Under the new guidelines, doctors would prescribe painkillers only after considering non-addictive pain relievers, behavioral changes and other options. The CDC also wants doctors to prescribe the lowest effective dose possible. And doctors should only continue prescribing the drugs if patients show significant improvement.
For short-term pain, the CDC recommends limiting opioids to three days of treatment, when possible.
The guidelines do not apply to doctors who specialize in treating severe pain due to cancer and other debilitating diseases.
Though the guidelines are voluntary, they could be widely adopted by hospitals, insurers and state and federal health systems.
Government officials have already tried multiple approaches to tackling painkiller abuse. The Food and Drug Administration restricted some widely-prescribed painkillers to limit refills. States like Florida and New York have cracked down on "pill mills" using databases to monitor what doctors are prescribing. And this week, Massachusetts signed into law a seven-day limit on first-time prescriptions for opioids—the first of its kind in the nation.
"Changing medical practice isn't quick and it isn't easy," Frieden said. "But we think the pendulum on pain management swung way too far toward the ready use of opioids."
The CDC rarely advises physicians on how to prescribe medications—a role typically delegated to professional societies and drug regulators.
FDA labeling for the drugs is broad, listing uses like "relief of moderate to severe pain." Guidelines by pain specialists provide more detail, but focus less on risks. The CDC guidelines put such warnings upfront: "Opioids are not first-line therapy," states the agency's first recommendation.
Local health authorities applauded the CDC for weighing in on the problem they face in their communities.
"The CDC is a respected source of information. Their guidelines carry weight," said Baltimore City Health Commissioner Dr. Leana Wen.
But some leading medical groups stopped short of embracing the recommendations. The American Medical Association, the largest professional group for physicians, cautioned that the guidelines could create problems if they steer patients toward pain treatments that aren't accessible or covered by insurance.
"If they produce unintended consequences, we will need to mitigate them" said Dr. Patrice Harris, in a statement. "They are not the final word."
In many ways, the guidelines are a return to older medical practice. Physicians trained in the 1960s and 1970s—amid a wave of urban heroin use—were taught to reserve opioids for the most severe forms of pain, such as cancer or end-of-life care. That approach remains accepted.
But in 1990s, some specialists argued that doctors were undertreating common forms of pain that could benefit from opioids, such as backaches and joint pain. The message was amplified by multimillion-dollar promotional campaigns for new, long-acting drugs like OxyContin, which was promoted as less addictive.
OxyContin's maker, Purdue Pharma, later agreed to plead guilty for misleading the public about the drug's risks.
"A whole generation of physicians grew up thinking they could use opiates pretty liberally," said Dr. Bruce Psaty, a professor at the University of Washington who also advises the FDA. "We are now in the process of re-educating ourselves and our patients."
Physicians must now find a "comfortable balance," Psaty said, using opioids carefully while making sure patients don't go untreated.
The CDC delayed its guidelines earlier this year following criticism from pain specialists, drugmakers and others.
Critics complained that the recommendations went too far and had mostly been developed behind closed doors by physicians who are biased against drug therapy. Instead of releasing the guidelines in January, as originally planned, the CDC agreed to re-open them to public input, receiving more than 4,000 comments over a 30-day period.
Critics said the proposal could block patient access to medications if adopted by health providers, insurers and hospitals. Such organizations often look to the federal government for health care policies.
Last week, an early sign of the guideline's impact surfaced in the Senate. Lawmakers there overwhelmingly passed a bill designed to combat opioid abuse, including a provision requiring the Veterans Administration to adopt the CDC recommendations.
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