By Pat Anson, PNN Editor 

The National Academies of Sciences, Engineering and Medicine (NASEM) is recommending that new clinical guidelines be developed for the treatment of short-term acute pain to reduce the risk of excess opioid prescribing.  

A 247-page report released by NASEM cites a lack of guidance on the appropriate type, strength and amount of opioid medication that should be prescribed to patients in acute pain, and claims that many patients are sent home with more pills than they need, which can later be misused. 

“Clinicians who prescribe opioids have to balance two distinct goals: relieving a patient’s severe pain, while minimizing the potential public health harms of opioid misuse and the resulting emotional distress to families and communities,” said Bernard Lo, president of the Greenwall Foundation and chair of a NASEM committee that wrote the report.  

The 15-member panel is composed primarily of academic, government and medical professionals. No pain sufferers or patient advocates served on the committee and the report gives no indication they were consulted with.    

NASEM is a private, nonprofit institution that was contracted by the FDA in 2018 to study the treatment of acute pain and develop a framework for new clinical guidelines.

Unlike the CDC’s controversial 2016 opioid guideline, which applies to a broad range of chronic pain conditions, NASEM is recommending that guidelines be developed for specific medical conditions or procedures that result in acute pain lasting less than 90 days. 

High-priority surgical procedures include cesarean (C-section) delivery, total knee replacement and wisdom tooth removal. Acute pain conditions such as low back pain, sickle cell disease, migraines and kidney stones are also considered top priorities for opioid guidelines.  

“There are still too many prescriptions written for opioid analgesics for durations of use longer than are appropriate for the medical need being addressed,” Janet Woodcock MD, Director  of the FDA Center for Drug Evaluation and Research, said in a statement.  

“The FDA’s efforts to address the opioid crisis must focus on encouraging ‘right size’ prescribing of opioid pain medication as well as reducing the number of people unnecessarily exposed to opioids, while ensuring appropriate access to address the medical needs of patients experiencing pain severe enough to warrant treatment with opioids.” 

‘Opioids Commonly Overprescribed’

The CDC guideline was only intended for primary care physicians treating chronic pain, but has been widely implemented throughout the healthcare system by other federal agencies, insurers, states and hospitals. Emergency room physicians are reluctant to prescribe opioids for trauma injuries and some patients recovering from surgery are being treated with Tylenol.    

The NASEM report suggests those efforts haven’t gone far enough. 

“Despite widespread efforts over the last five years to reduce opioid prescribing, opioids are commonly overprescribed for acute pain. In addition, the amount of opioids prescribed for acute pain varies by provider, hospital, and geographical region,” NASEM found. 

The report claims that post-surgical patients consume only half of the opioids prescribed to them, and between 6 percent and 14 percent of patients who receive opioids after surgery or in the emergency room continue to use them six to 12 months later. 

Those claims are at odds with a large Mayo Clinic study found that only about 1% of patients given opioids in emergency rooms went on to long term use. Another large study conducted by Harvard Medical School found less than 1% of patients being treated with opioids for post-surgical pain were later diagnosed with opioid misuse.  

Guidance Gaps

The NASEM report identifies several gaps in current guidelines for acute pain and recommends more research on nonopioid alternatives, outcomes of opioid prescribing on different patient populations, and the amount of opioids prescribed and leftover after treatment. 

As PNN has reported, the CDC is already in the initial stages of updating its 2016 guideline to include recommendations for treating acute pain and how to taper patients safely off opioids. The update likely won’t be completed until late 2021. 

An FDA spokesman described the work of the two agencies as complementary and with similar objectives.   

“We acknowledge the work CDC has taken in developing federal guidelines on pain management and the use of opioids, which are based on expert opinion. Our work seeks to build on that work by generating evidence-based guidelines where needed,” Nathan Arnold said in an email to PNN. 

“The guidelines we generate would be distinct from this corresponding effort by the CDC, in that our effort would be indication-specific, and would be based on prospectively gathered evidence drawn from evaluations of clinical practice and the treatment of pain. Our work could potentially inform drug labelling. These two efforts are highly complementary and serve adjacent goals.” 

One of the co-authors of the CDC guideline is involved in both efforts. Roger Chou, MD, a primary care physician and professor at Oregon Health & Science University School of Medicine, served on the NASEM committee.  Chou is also directing research on three CDC-funded studies on opioid and non-opioid treatments for chronic pain, as well as a fourth study on acute pain treatment. Those studies will be used by CDC to update its current guideline.

Chou recently collaborated with Physicians for Responsible Opioid Prescribing (PROP), an influential anti-opioid activist group that seeks drastic reductions in the use of opioid medication. Chou co-authored an article with PROP President Dr. Jane Ballantyne and PROP board member Dr. Anna Lembke that encourages doctors to taper “every patient receiving long term opioid therapy.”