By Pat Anson, Editor

An opioid prescribing guideline adopted in 2013 at Temple University Hospital in Philadelphia may provide a sneak peek at the possible impact of similar guidelines being considered by the Centers for Disease Control and Prevention (CDC).

Temple University’s guidelines, which discourage opioid prescribing for many emergency room patients suffering from acute or chronic pain, resulted in an “immediate and sustained impact” on rates of opioid prescribing, according to research published in the Journal of Emergency Medicine.

In a study of over 13,000 patient visits, the rate of opioid prescribing was quickly reduced by about a third, falling from nearly 53% of emergency room visits before the guideline to about 34% a year later. The patients were being treated for dental, neck, back and chronic non-cancer pain.

The opioid guidelines were supported by all 31 of the hospital’s emergency room physicians who completed a survey on their prescribing practices. Most of the doctors (97%) felt the guideline facilitated discussions with patients when opioids were withheld, and nearly three-quarters said they encountered “less hostility” from patients since adoption of the guideline.

Only 13% of the doctors believe patients with legitimate reasons for opioids were denied appropriate care. A large majority – 84% of the doctors -- disagreed or strongly disagreed that patients were denied appropriate pain relief.

The researchers did not ask any pain patients what they thought about their hospital care.

“Emergency physicians have identified themselves as targets for patients who seek opioids for nonmedical purposes, yet it can be difficult for clinicians to distinguish drug seeking behavior from legitimate need. Recognizing the importance of clinician discretion at the bedside, adherence to our guideline was voluntary,” said Daniel del Portal, MD, Assistant Professor of Clinical Emergency Medicine at the Lewis Katz School of Medicine at Temple University, who was principal investigator of the study.

The CDC also considers its draft guidelines voluntary for primary care physicians, although many experts believe they will quickly be adopted as “standards of practice” by all doctors who prescribe opioids – just as they were at the hospital.

The Temple University guidelines differ from those of the CDC because they are designed specifically for emergency room physicians. They discourage doctors from prescribing opioids for dental pain, back pain, migraines, gastroparesis or chronic abdominal pain; and recommend that patients not be discharged with more than 7 days supply of opioids (the CDC recommends 3 days supply). The hospital’s guidelines also recommend that long acting opioids such as OxyContin, morphine and methadone not be prescribed; and that “less addictive therapies” such as NSAIDs or acetaminophen be used instead for pain relief.  

“We acknowledge the myriad challenges to addressing issues of chemical dependence and opioid abuse. We do not pretend that a guideline alone will solve this problem, but rather we believe that guidelines are one of a number of tools that should be considered in parallel,” said del Portal.

“In contrast to electronic prescription drug monitoring programs, which show promise but require significant infrastructure and regulation, an easily implemented guideline empowers physicians and protects patients from the well documented dangers of opioid misuse.”

He also acknowledged that limits on opioid prescribing may result in more drug abuse and addiction.

“Heroin overdose deaths have continued to rise, even more dramatically since the plateau of nationwide opioid prescriptions
after 2011. While experts point to the rise in opioid prescriptions as a major contributor to heroin deaths, we are mindful that limiting the supply of opioids may provide a catalyst for drug substitution,” he said. 

The public comment period on the CDC's draft guideline continues until January 13th. You can make a comment by clicking here. 

The proposed prescribing guidelines and the reasoning behind them can be found in a 56-page report you can see by clicking here.