Saturday, April 23, 2016

AMA versus CDC Patient Education On Opioids

CDC Poster On Opioids For Chronic Pain

The easiest place to start the critique of the initiative to stop opioid overuse in this country is the patient information products for both the CDC and the AMA.  The CDC poster on this subject is shown above and is public domain.  There is more detailed patient information from the CDC at Guideline Information for Patients.  The AMA page on the same subject is at this link.  AMA web site materials are copyrighted and I did not think it was worth the effort to attempt to get that permission.   It is available free online.  How do these guidelines compare with one another and are they likely to be useful to patients?

On inspection they both seem to warn patients that there are potential health problems including addiction and death from taking opioids.  The CDC graphic advises  the patient to actively collaborate with their physician around any potential opioid prescription.  It suggests that the physician in this case will present a number of non-opioid options and a receptive patient will decide how to use them.  Apart from the 1 in 4 statistic it is almost a fairy tale approach to the problem of addiction.  Keep in mind that direct-to-consumer advertising these days frequently end with a staccato-like recitation of side effects "including death" and pharmaceutical companies are not deterred from adding that qualifier.  That suggests to me that these dire warnings are really not a deterrent to people looking for what appears to be a "cure" - at least in some cases.  The more detailed approach from the CDC guideline seems more reasonable, but both do not take into account unconscious factors on the part of both the patient and physician.  The AMA version is seriously watered down, but both lack realistic information about addiction works.

The real issue with opioids is not that 1 in 4 people end up addicted to them.  That 1 in 4 number is after all an intent-to-treat number.  There are probably at least that many people who don't tolerate opioids at all, even on an acute basis.  Taking those people out, bumps up the number of potentially addicted to 1 in 3.  The real problem here is how the addiction occurs and the implications for primary and secondary prevention.  I can tell anyone who cares to listen that the secondary prevention aspect of opioid addiction is a long and arduous process, with no guarantee of a cure at the end of it.  Imagine that you have just started a family and started out in the workplace when the addiction occurs.  Contrary to all of the hype about medication assisted treatment with buprenorphine or naltrexone, this kind of treatment does not work well for everyone.  Addiction to an opioid may require that you participate in some form of education based treatment for up to three months or take long absences from your work and family to live in sober structured environments.  The structured environments are costly and the quality of these settings cannot be assured.  What the AMA and CDC references do not show is that if you have an addiction - you might be in a very expensive treatment program and still not be interested in stopping the opiate.  You may not feel ready to quit after one or more of these treatments.  The real danger of an addiction is that it alters your conscious state to continue the addiction, even in an environment where you are supposed to be learning how to get sober and maintain sobriety.

The AMA and CDC resources are short on this aspect of opioid addiction.  These pages should tell people a couple of other things aimed at preventing addiction rather than recognizing addiction and trying to treat it after it happens.  Here are the bullet points:

1.  Practically all people at-risk know it after they have taken the first few doses of medication.  The opioid makes them feel euphoric or ecstatic.  Contrary to the popular image of heroin addicts falling asleep, the at-risk population is energized and may feel like they have become more productive than they have ever been.  That response establishes a dangerous link between productivity and opioid use.  The at-risk population also has an enhanced perception of themselves.  They may suddenly perceive themselves as having become the person they always wanted to be.  That can include the perception of a number of positive personal qualities including confidence, intelligence, and creativity.  All of these reinforcing qualities disappear once tolerance to the drug occurs.

2.  People at-risk may notice that long standing anxiety, insomnia or depression is suddenly gone.  As an example, there are many people with social anxiety in childhood and early adult life.  Social anxiety is a condition where the person is overly concerned about being judged when they are out in public.  The associated concerns may be that they will be embarrassed or humiliated.  There is often an associated performance anxiety in certain situations.  This part of the at-risk population may notice that all of those concerns are completely gone when they start taking opioids.  All of these reinforcing qualities disappear once tolerance to the drug occurs and anxiety, depression, and insomnia recur (often amplified) during withdrawal and detoxification.

3.   The concept that opioids are medications that can reinforce their own use whether or not they actually work for pain is a difficult one to grasp.  In other words, the at-risk population may want to keep taking opioids even in cases where they do absolutely nothing to alleviate pain.  In this case it is not a question of tolerance to the analgesic effects of opioids.  The opioids did not work in the first place.  Opioids are only moderately effective for chronic pain in the first place and those effects are on par with antidepressants and anticonvulsants like gabapentin.

4.  Opioids can change your baseline personality and cause you to do things that you ordinarily would never have done.   Once an addiction has been established decision-making is in the service of maintaining the addiction.  That can include any number of legal and moral decisions that that involve the people who are closest to the person with the addiction.  The repercussions of these acts are not fully appreciated until the person is detoxified and is sober from the opioid.

5.  Opioids are legendary in the American culture.  The American culture strongly reinforces the place of intoxicants in the lives of even average Americans.  Intoxicants are in the literature, the media, and even day-to-day conversations.  People tend to hoard their unused opioids, exchange them with their friends and family, and talk about the effect of these drugs with their neighbors.  To illustrate, an acquaintance of mine recently had arthroscopic surgery of the knee.  He was in a large post-op recovery area with 8 other people.  Nursing staff were approaching people and asking them what they wanted for pain relief.  The choices were hydromorphone (Dilaudid) - a potent opioid, oxycodone-acetaminophen (Percocet) - a less potent opioid, and ibuprofen - a non-opioid.  The vote in the recovery room was 8-0 in favor of hydromorphone.  That vote parallels the disproportionate increase in emergency department visits for complications from hydromorphone relative to all other opioids.   Of course there are many variables at play, but I am suggesting at least one of them is the reputation that hydromorphone has in American culture as a potent euphoria producing opioid.

6.  Part of the American legend is that opioids are the magic bullet for pain.  The corollary is that if the doctor would just give me enough of this drug - my pain would be gone.  The important distinction here is chronic pain.  Across large populations there is no medication that will get rid of chronic pain.  For many people, no treatment at all, treatment with a non-opioid medication, or treatment with a different modality like cognitive-behavioral therapy works much better.

There are all important points for people to know before they start taking opioids.  I think that a clinical trial is indicated to see if people with this information do better than those without it.  If I was designing that trial, I would have an intervention that advised people to stop taking the medication and call the physician immediately if they experienced any change in their conscious state like the ones I described in points 1, 2 or 3 above.

Stopping opioid addiction well before it is established is the preferred intervention.  There is certainly effective treatment once an addiction has been established but it can be long, expensive, difficult, and the outcome is never guaranteed.  Anyone who starts to take an opioid needs that level of transparency.

George Dawson, MD, DLFAPA         

Attribution:  The infographic at the top of this post is from the CDC web site and is reused per their general information about being in the public domain.  The poster is available at:


  1. Prescriptions for a one month supply with a refill after a routine surgery need to stop too. I've had major surgery including two osteotomies and I took them for two days. Of course, it was easy for me because I HATED how Vicodin made me feel. Irritable and nauseated. Which I am thankful for.

    I find it amusing (and somewhat sickening) that the number now is the realistic 1/4 which all of us skeptics kept saying in the 1990s while the arrogant foolish KOLs were telling us we were ignorant for not believing it was rare, i.e. Porter and Jick, 1980 NEJM, 4 in 12,000 which anyone with common sense knew was bogus.

    1/3000 vs 1/3? Off by a factor of a thousand.

    1. There was a paper in JAMA Internal Medicine a few years back that showed that 7% of post-op patients were still taking their post-op opioid 1 year after the surgery. I lecture a diverse group of residents and physicians each month and their feedback to me on this paper was:

      1. Some surgeons have very clear post-op orders for opioids and no extensions beyond that point. Some will tell their patients after a month or two to return to their primary care physicians for pain control.

      2. There appear to be a group of patients, especially at teaching sites who learn how to use the in-call system of residents to extend these prescriptions.

      3. My own experience with trying to treat chronic pain patients has benefitted from learning some of the opioid restrictions used by some specialists for treating pain disorders associate with that specialty. When I was in a large multispecialty clinic it was very useful to call up one of those docs and say: "I have this patient who I think is being treated far too aggressively with opioids by a pain clinic. How do you manage the pain for this disorder."

      The differences in management could be as far apart as 10 Percocet tabs per months versus an implanted hydromorphone pump for the same pain problem.

      Practically all of those experiences come from the difference between thinking that you are going to eliminate pain by aggressive treatment of opioids versus a more workable plan.

      There needs to be much more standardization in pain protocols and I think some evidence that overly aggressive pain management with opioids actually does something. I was after all seeing these folks because they were still in a pain crisis and now suicidal and depressed.

  2. As much as personalized medicine is over-hyped, I hope science progresses on that front. I have met a fair number of people who have one pain med work for them (or for a certain type of pain) where another doesn't. I'll leave out the specifics but count me as one of those facing this dilemma. All of the standardization so far does nothing to address is.

    1. Standardization is a tool of the managerial class. They don't comprehend individual differences or the fact that every human being ever born is unique. When managed care gets their hands on personalized medicine it will be a few flavors for their current "population based medicine".

      That very term says it all.