In another indication that the C.D.C. sees these new guidelines as a course-correction to the earlier ones, the agency now suggests that when patients test positive for illicit substances, doctors should offer counseling, treatment and, when necessary, careful tapering. Because doctors had interpreted the 2016 dosing limits narrowly, some had worked up one-strike policies and were summarily ejecting such patients.
Dr. Jones said that such results should instead be considered one piece of diagnostic information among many. An unduly high level of opioids could indicate the patient still has untreated pain or even a substance use disorder. “If you instead retain the patient and have those conversations, there’s now an opportunity to improve the patient’s life,” he said.
Drawing from a mountain of research that accumulated in recent years, the proposed guidelines also offer extensive recommendations for the treatment of acute pain — short-term pain that can come with an injury like a broken bone or the aftermath of surgery. They advise against prescribing opioids, except for traumatic injuries, such as burns and auto accidents.
In granular detail, they compare the relief provided by opioids to that offered by alternatives such as exercise and acupuncture and other drugs. And they give fine-tuned recommendations for discrete areas of pain, such as lower back, knees and neck.
The guidelines, for example, note that opioids should not be used for episodic migraines. They endorse, among other treatments, heat therapy and weight loss for knee osteoarthritis, and, for neck pain, suggest options like yoga, tai chi, qiqong, massage and acupuncture.
Dr. Marie Hanna, an associate professor of anesthesia and critical care at Johns Hopkins University School of Medicine, said she was particularly enthusiastic about the depth and breadth of research that the guidelines provide in support of nonopioid treatments, including manual manipulation, laser therapy and exercise.
“This is what we’ve been talking about for years, but no one was listening. Now we have the evidence to show that these treatments are effective. I’m very optimistic,” added Dr. Hanna, a member of the American Academy of Pain Medicine, an organization of pain researchers and providers across several disciplines.
