Treating Chronic Pain Just Got Harder for Primary Care Doctors

By Floyd Arthur

Amidst a still-swirling controversy, the Centers for Disease Control unveiled its new opioid guidelines last week; as expected, they mainly target primary care physicians treating chronic pain. The final guidelines differ little from the draft released last December, although some specific dose recommendations have been removed.

Probably the most controversial of the agency’s 12 non-binding recommendations is No. 1 -- the edict that opioids should not be first line therapy for chronic pain. Instead, the agency recommends non-opioid pain relievers and nonpharmacologic therapies, such as exercise and cognitive behavioral therapy, for the treatment of most types of chronic noncancer pain.

The guidelines were issued in response to the nation’s current epidemic of opioid misuse, which  is responsible for about 40 deaths each day. Calling the widespread misuse “doctor-driven” CDC director Tom M.D., MPH, said in a news conference, "For the vast majority of patients, the known, serious and all too often fatal risks far outweigh the unproven and transient benefits, and there are safer alternatives."  

The guidelines do not address those “safer alternatives” specifically, nor do they speak to the issue of insurance reimbursement for nonpharmacologic therapies, a sticking point brought up my many physician groups.

The Complexities of Treating Chronic Pain

Although the CDC guidelines are technically non-binding, they are certain to have a chilling effect on primary care physicians treating chronic pain. Legislative mandates that set arbitrary limits on the number of pain pills doctors can prescribe add another layer of complexity in many states.

Take the case of Dr. Robert L. Wergin, chairman of the board of the American Academy for Family Physicians and a primary care physician in the rural town of Milford, Nebraska. Wergin is the only doctor in the small town of just over 2,000 residents, many of whom he has treated for dozens of years. He does not prescribe opiates lightly, but for patients with severe, chronic pain, he knows they are the treatment of last resort.

“I have a patient with inoperable spinal stenosis who needs to be able to keep chopping wood to heat his home,” said Dr. Wergin in an interview with the New York Times. “A one-size-fits-all prescription algorithm just doesn’t fit him. But I have to comply.”

Additionally, he points out, many of his patients lack the wherewithal to visit pain specialists in  Lincoln, 30 miles away. Nor can they afford to pay for physical or psychological therapy, which typically carry a hefty co-payment, if they are covered by insurance at all.

And there are contraindications to non-opiate pain medicines, particularly in the elderly. Nonsteroidal anti-inflammatory drugs, in particular, are not recommended for long term use in patients over the age of 65. Nor are benzodiazepines, which are sometimes given to provide adjunctive relief for chronic pain.

A Flawed Approach to Treating Chronic Pain?

Although the American Medical Association was “largely supportive” of the CDC guidelines, the group took issue with the lack of patient input when the agency issues the draft guidelines last year.

Said James L. Madara, MD, Executive Vice President and CEO of the AMA, "The guidelines and supporting discussion are devoid of a patient-centered view and any real acknowledgment or empathy of the problems chronic pain patients may face," he said.

Additionally, the evidence supporting the recommendations is “low to very low,” said Sharon Hertz, director of the Division of Anesthesia, Analgesia and Addiction Products for the FDA.

And in a formal objection filed with the CDC last year, the National Institute of Health’s Interagency Pain Research Coordinating Committee echoed her sentiments, calling the guidelines “ridiculous” and “an embarrassment.” The panel consists of representatives from the FDA, the Department of Defense, the Agency for Healthcare Research and Quality, the Department of Veterans Affairs and the CDC.