Even though I listen to many, many podcasts, I rarely feel the need to recommend one. However, this particular story is one that is powerfully relevant to today even it may not seem so. It is about the shadow that we all live under, a shadow that that we rarely contemplate, a shadow that no one could have ever conceived could be made darker through tweets. That shadow that I’m referring to, of course, is the possibility of nuclear war and the annihilation of our species as a result.
Dan Carlin’s Hardcore History is an incredible series that provides an in-depth and balanced look at a wide range of historical subjects and time-periods. I admit I’ve only listened to his World War I series (Count Down to Armageddon) and this one, The Destroyer of Worlds. Even if you’re not a history buff, this podcast is a must listen because we still live in the nuclear age. Nuclear war is still a possibility. Perhaps less so after the Cold War but these weapons and their implicit threat have not gone away. This podcast presents an excellent primer on the subject if you’ve never contemplated what having nuclear weapons really mean to the fate of our species.
Carlin explains that the invention of nuclear weapons was a paradigm-shifting event the likes of which humanity has never previously grappled and these new implements of destruction inexorably shaped the reality of this new world. He walks through the Cold War up until the Cuban Missile crisis through the lens of nuclear weapons and how they influenced decisions on both sides of the divide during this period. It’s a fascinating perspective, which I have not considered when learning about historical topics such as the Korean War. Carlin presents a remarkably nuanced and human discussion of the thought processes of various military and political figures and does his best to argue various different historical perspectives. I think this latter point is particularly important because history is most often presented through a single lens when in reality humans are complex multifaceted entities. History distills particular leaders like Truman and Eisenhower almost down to a stereotype. I greatly appreciated Carlin’s endeavor to describe this figures much more holistically.
Carlin peppers the historical events with a more philosophical discourse on the implications of nuclear weapons. He really does an excellent job of placing the advent of nuclear war in a global frame and anchors this frame based on the course of human history up to that moment. His metaphor is perfect; humans in the 1940s and 50s were children given a gun. They had the power to kill in a way thought inconceivable before 1945, but no one had any idea on the right way to use it (if at all) or what it really meant to have it in the first place.
Of particular significance, he also includes first-hand accounts of what it is like for a human being to be exposed to one of these hellish devices: accounts of survivors of Hiroshima. I never even new such accounts existed and they are truly horrifying. Everyone should listen to this podcast simply to hear these stories alone.
Most relevant and poignant for today, though, is the huge burden of responsibility placed on leaders such as Kennedy and Khrushchev during the Cuban Missile Crisis. Carlin’s insights on what these two leaders were thinking at the time are excellent. Both leaders understand their actions may lead to nuclear war but at the same time cannot show any signs of weakness or capitulation. Heads of state have been doing this dance ever since there were things we now call countries but the dance chanced dramatically once humanity now had a tool that could literally annihilate civilizations.
But what really struck me about this podcast is my own terrifying hypothetical that seems to become less hypothetical every day: What if Trump was in Kennedy’s shoes in 1962? What type of world would be living in today? I know how I would answer. I doubt most people have even thought about the question.
Check out our August Recess Guide so you can petition your local congressperson on science and technology and other policy issues! It’s your 1st amendment right to hold your congressperson accountable. Don’t let them relax while they’re on recess!
I contributed the piece below on a Department of Labor rule than can have a huge impact on Postdoc pay.
Fate of Department of Labor rule may impact postdoc pay
On May 23, 2016, the Department of Labor (DOL) announced a new rule allowing overtime pay for certain professionals making less than $47,476, including most postdoctoral researchers. The rule would effectively incentivize a pay increase for postdocs making less than $47,476. Indeed, after the announcement, the National Institutes of Health (NIH) adopted a new pay scale for one of its most widely awarded postdoctoral fellowships. However, the rule, which was supposed to take effect December 1, 2016, was blocked by a federal judge in Texas on November 22, 2016. The rule, along with the potential postdoc pay raise, has been frozen, awaiting further determination by the court ever since.
On Wednesday, July 26, 2017, the DOL published a Request for Information (RFI) in the Federal Register seeking responses to a series of detailed questions concerning this rule, likely in anticipation of pending legal action (the legal challenge to the rule is currently being reviewed by the Fifth Circuit Court of Appeals). According to the DOL, “the RFI is an opportunity for the public to provide information that will aid the department in formulating a proposal to revise these regulations.” The future of the much-anticipated increase in postdoc pay may depend on the legal fate of this rule. Public comments must be submitted on or before September 25, 2017, and additional instructions can be found at Regulations.gov referencing the Regulatory Information Number 1235-AA20. Read more about the rule and the RFI in RISE Stronger’s policy and action brief on this topic.
I recently became involved with the science advocacy group RISE Stronger. The group’s Mission is to “To build a dynamic, strategic movement of politically engaged communities that demand a responsible and accountable government which serves the interests of the people.”
One component of organization is the Science and Technology Working Group, which acts as a watchdog group for science in government. Every week we compile and release a newsletter on developments in Science Policy and reporting on any actions the Trump Administration or Congress have taken in the previous week that may impact the use of science in policy making or government actions on science issues. I am happy to have contributed a story on the opioid epidemic to last week’s summary.
Since taking over at the Department of Justice (DOJ), Attorney General Jeff Sessions has been attempting to reignite the “War on Drugs” (for example, he issued a memo to federal prosecutors calling for the them to seek the harshest possible sentence when dealing with low-level drug offenders, the exact opposite of Obama-era guidance).
Sessions now has his sites on state-run medical marijuana programs (marijuana is still listed as a Schedule 1 illegal drug according to the DEA, the most severe categorization for drugs). In May, Sessions tried to pressure Congress to not stop him from authorizing the DOJ to prosecute medical marijuana clinics and patients.
Sessions attack on medical marijuana would be extremely harmful to not only the patients that benefit from medical marijuana but may even increase opioid overdose deaths in those states (there’s actually a growing body of scientific evidence that opioid overdose deaths are reduced in states with legalization of marijuana; I plan to write a more detailed post on this in the near future).
Thankfully the Senate has taken measures to prevent Sessions from being able to take action against medical marijuana. A bipartisan committee approved an amendment to the 2018 Commerce, Justice and Science appropriations bill. The amendment does not allow DOJ to use funds to prevent states from “implementing their own state laws that authorize the use, distribution, possession or cultivation of medical marijuana.” In essence, even if Sessions instructed Federal law enforcement agents to target medical marijuana clinics and patients, they would be unable to do so because it would be illegal to use any federal dollars to carry out this action.
Time will tell what other ways Sessions will try revive antiquated drug policy (if he survives his tenure as AG that is). A study in the Lancet last year examined the public health impact of drug policy throughout the world (future post on this too) and concluded, among other things, that “policing practices undertaken in the name of the public good have demonstrably worsened public health outcomes.” Clearly, Sessions didn’t read this report…
When a politician is in his or her final few month in office (because either they lost their re-election or simply decided not to or can’t run), they call this the “lame duck” period. President Obama’s last few months in office were anything but “lame”.
On December 14, 2016, in a rare move of bipartisanship, Obama signed into law the massive 21st Century Cures Act. This law provides a boost in funding for NIH (which includes $1.8 billion for the cancer moonshot initiative), changes to the drug approval process through the FDA, and ambitious mental health reform. This huge bill has the stated purpose of “To accelerate the discovery, development, and delivery of 21st century cures, and for other purposes.”
I’m willing to bet many people were totally unaware of this legislation that could help millions. There are some parts that are controversial and, as with any large piece of legislation, some provision that benefit this interest or that have been worked in (the changes to drug approval at the FDA will likely benefit Big Pharma). I’m not a health policy expert so I’m not about to go through and discuss line-by-line the winners and losers in this law (if you want a more in depth discussion: NPR, Washington Post, and PBS have all written articles on the law).
There’s one piece of the law that I am particularly thrilled about: $1 billion over 2 years for treatment for opioid addiction. That’s rights billion, with a “B”. The money is to be distributed to states in the form of block grants (block grants are in essence a large allocation of federal money to be used for a specific purpose given to states but the details of how that money is used is decided by the states themselves).
This is an unprecedented amount of funding earmarked exclusively to fight the opioid epidemic that is still raging in the US. The funding is to be used for expanding and increasing accessibility to treatment, such as life saving medication-assisted treatments such as methadone and buprenorphine. The federal money will also be used to train healthcare professionals to better care for people dealing with addiction, and a comparatively smaller amount for conducting research on how best to fight the epidemic, and other provisions.
I’ve written about methadone and buprenorphine and their effectiveness ad nauseam on this site and I am personally and thrilled to see a massive federal effort to increase access to these vital tools in the fight against the opioid crisis
The Cures Act comes on the heels of another promising piece of legislation, the Comprehensive Addiction and Recovery Act (CARA), signed into law by President Obama on July 13, 2016. This law includes provisions to expand the availability of naloxone–the medication used to save people from the effects of opioid overdose–to first responders, improve prescription drug monitoring programs, make it easier for healthcare providers to administer, dispense, or prescribe medication-assisted treatments, and other provisions.
The combination of these two pieces of legislation is a promising and much needed initial federal response.
However, this huge boost in funds for treatment in the Cures Act is only for 2-years. President Trump’s budget for FY18 would add $500 million for opioid addiction but most analysts think this is just a sneaky way of making it seem as if he’s supporting addiction treatment when the money has already been written in as part of the Cures Act. Further, his cuts to the Department of Health and Human Services (which contains the NIH and other agencies that administer the Cures and CARA laws) would make it difficult to launch any type of effective response to the crisis.
Regardless of how things shake out, Trump’s massive cuts for everything that’s not the Department of Defense will likely hurt the fight against the opioid epidemic too. The real question is by how much?
Instead, I’ll present some of the key findings from a relatively new (April 2016) review article about the science of sexual orientation by JM Bailey and colleagues in the journal Psychological Science in the Public Interest. This is by far one of the most comprehensive and most even handed review articles written on the subject. The authors take an extremely academic approach because let’s face, the science surrounding sexual orientation has been used and abused by both pro- and anti- gay rights folks. (note: this article does not really discuss with transgenderism or gender identity issues)
This article is too long to go into all the details so instead I’m just going to present the main highlights that I prepared for a research report a few months back. Enjoy!
Political controversies pertaining to the acceptance of non-heterosexual (lesbian, gay, bisexual) orientation often overlap with controversies surrounding the science of sexual orientation. In an attempt to clarify the erroneous use of scientific information from both sides of the debate, this article 1) provides a comprehensive review of the current science of sexual orientation, and 2) considers the relevance of scientific findings to political discussions on sexual orientation.
Top Takeaways from the Review:
The scientific evidence strongly supports non-social versus social causes of sexual orientation.
The science of sexual orientation is often poorly used in political debates but scientific evidence can be relevant to specific, limited number of issues that may have political consequences.
The scientific evidence strongly supports non-social versus social causes of sexual orientation (nature vs nurture).
Prevalence of non-heterosexual orientation (analysis of 9 large studies): 5% of U.S. adults.
Summary of the major, scientifically well-founded findings supporting non-social causes:
Gender non-conformity during childhood (before the onset of sexual attraction) strongly correlates with non-heterosexuality as an adult.
Occurrence of same-sex behavior has been documented in hundreds of species and regular occurrence of such behavior in a few species (mostly primates, sheep).
Reported differences in the structure of a specific brain region (SDN-POA) between heterosexual and homosexual men.
Hormone-induced changes in the SDN-POA during development in animal studies and subsequent altered adult sexual behavior (the organizational hypothesis).
Reports of males reared as females but who exhibit heterosexual attractions as adults.
Twin studies suggest only moderate genetic/heritable influence on sexual orientation.
Several reports identify a region on the X chromosome associated with homosexuality.
The most consistent finding is that homosexual men tend to have a greater number of biological older brothers than heterosexual men. (fraternal-birth-order effect)
The science of sexual orientation is often poorly used in political debates, but scientific evidence can be relevant to a specific, limited number of issues that may have political consequences.
The question of whether sexual orientation is a “choice” is logically and semantically confusing and cannot be scientifically proven. It should not be included in political discussions.
Examples of scientifically reasonable questions include:
Is sexual orientation determined by non-social (genetic/hormonal/etc.) or social causes? (nature vs nurture)
Is sexual orientation primarily determined by genetics or environment?
Specific cases in which scientific evidence can be used to inform political decisions:
The belief that homosexual people recruit others to homosexuality (recruitment hypothesis). This type of belief was espoused by by President Museveni of Uganda in 2014 and was used to justify Uganda’s notorious anti-homosexuality bill (since repealed).
No studies exist that provide any type of evidence in support of this hypothesis.
The article points out how the “War on Drugs”, the term used to collectively describe the laws penalizing drug use, has had a wide-range of negative effects. For example, the US has the highest incarceration rate in the world and about half of those arrests are due to drug-related arrests.
The health effects have been drastic as well. Stigma against opioid replacement therapies like methadone has resulted in increased deaths due to opioid overdose in countries that limit access. Stigma and discrimination against addicts, as well of fear of punishment for for usage, often leads away from health care services to unsafe drug-use practices that can spread HIV and Hepatitis C, and other unintended poor-health outcomes.
Importantly, the editors call for rational, evidence-based, drug-specific approach to regulation and strong involvement of the scientific and medical communities. Obviously, the risks of something like marijuana are much lower than for heroin but how will drug policy reflect this? Research is required to support any efforts in order to identify the best practices and strategies.
The editors point out that a recent article in the Lancet “concluded that governments should decriminalise minor drug offences, strengthen health and social sector approaches, move cautiously towards regulated drug markets where possible, and scientifically evaluate the outcomes to build pragmatic and rational policy.”
Above all, a change in drug policy must benefit human health and there will be no “one size fits all” approach. The road ahead is difficult but one thing is certain, the road that led us here is a dead end. The “War on Drugs” has failed; the call now is to develop a national and international drug policy that won’t.
One of the great questions in the addiction field is why do some people become full-blown addicts while other people can use drugs occasionally without progressing to anything more serious? One part the answer definitely has to do with the drug itself. For example, heroin causes a more intensely pleasurable high than cocaine and people that try heroin are more likely to become addicted to it than cocaine. But that’s not the whole story.
I’ve written previously about how a negative, stressful environment can have long-lasting negative impacts on the development of a child’s brain (also known as early-life stress of ELS). ELS such as childhood abuse (physical or sexual) and neglect can increase the risk for a whole host of problems as an adult such as depression, bipolar disorder, PTSD, and of course drug and alcohol abuse. There’s even a risk for more physical ailments like obesity, migraines, cardiovascular disease, diabetes, and more.
Childhood abuse/neglect = psychological and physical problems as an adult.
This idea doesn’t sound too controversial but believe it or not, the idea that a bad or stressful situation as a child would do anything to you as an adult was laughed away as not possible. It’s only within the last decade or so that a wealth of research has supported this idea that ELS can physically change the brain and that these changes can last through the abused child’s entire life.
This recent review paper (published in the journal Neuron) is an excellent, albeit technical, summary of dozens research papers done on this subject and the underlying biology behind their findings.
I especially love the quotes the author included at the beginning of the article:
And even more recently, yet another research paper has come out that highlights how important childhood is for the development of the brain and how a stressful childhood environment can impact the function of a person as an adult.
This most recent report, published in the journal Neuropscyhopharmacology concludes that early childhood abuse affects male and females differently. That is to say that the physical changes that occur in the brain are distinct for men and women who were abused as children.
Studies like this one are done by examining the brains of adults who were abused as kids and then comparing the activity or structure of different parts of the brain to the brains of adults who were not abused. The general technique of examining the structure or activity of the brain in a living human being is called neuroimaging and includes a range of techniques such as MRI, PET, fMRI, and others. (I’ve written about some of these techniques before. In fact, the development of better methods to image the brain is a huge are of research in the neuroscience field).
However, this study did not examine behavioral differences in the subjects, but as I said above, a great number of many other studies have looked at the psychological consequences of ELS. But this paper is really primarily interested in the gender differences in the brains of adults that have been abused as kids.
*Note: the following discussion is entirely my own and is not mentioned or alluded to by the author’s of this study at all.
This work—and the many studies that preceded it—has important implications because as a society, we have to realize that part of our personality/intelligence/character/etc. is determined by our genetics while the other part totally depends on the environment we are born into. I don’t want to extrapolate too much but the idea that childhood abuse can increase the risk of psychological problems as an adult also supports the broader notion that a great deal of a person’s success is determined by entirely random circumstances.
The science shows that a child born into a household rife with abuse will have more chance of suffering from a psychological problem (such as addiction) as an adult than someone who was born into a more stable life. The psychological problem could hurt that person’s ability to study in school or to hold down a job. And the tragic irony, of course, is that no child gets to choose the conditions under which they are born. A child, born completely without a choice of any kind over whether or not he or she will be abused, can still suffer the consequences of it (and blame for it) as an adult.
As a society, we often always blame a person’s failures as brought on by his or her own personal failings, but what if a person’s childhood plays an important role in why that person might have failed? How, as a society, do we incorporate this information into the idea of ourselves as having complete control over our minds and our destinies, when we very clearly do not? As an adult, how much of a person’s personality is really “their own problem” when research like this clearly show that ELS impacts a person well after the abuse has ended?
If the environment a child is born into has a tangible, physical effect on how the brain functions as an adult, than this problem is more than a social or an economic one: this is a matter of public health. Studies that support findings such as these provide empirical significance for public policy and public services for child care such as universal pre-K, increased availability of daycare, health insurance/medical access for children, increased and equitable funding for all public schools regardless of the economic situation of the district that school happens to be located in, etc.
One of our goals as a society (if indeed we believe ourselves to be a functioning society…the success of Donald Trump’s candidacy raises some serious doubts…but I digress) is the improvement of the lives of ALL of our citizens and securing the prosperity of the society for future generations. Reducing childhood poverty and abuse quite literally could help secure the future generations themselves and improve the ability of any child to grow up to become a successful and productive adult.
Public programs are essential because the unfortunate reality for many people born into poverty is that they must work all the time at low paying jobs in order to simply survive and may not be able to give their children all the advantages of a wealthier family. And this is where government and public policy step in, to correct the imbalances and unfairness inherent to the randomness of life and level the playing field for all peoples. Of course, the specific programs and policies to reduce childhood poverty and abuse would need to be evaluated empirically themselves to guarantee an important improvement in development of the brain and health of the child when he/she grows up.
And this is the real power of neuroscience and basic scientific research papers like this one. Research into how our brains operate in real-life situations reveal a side of our minds and our personalities that we never may have considered before and the huge implications this can have for society. The brain is a complex machine and just like other machines it can be broken.
Of course, we shouldn’t extrapolate too much and say that, for example, a drug addict who was abused as a child is not responsible for anything they’ve ever done in between. But is important to recognize all the mitigating factors at play in a person’s success and simply dismiss someone’s problems as “their own personal responsibility.” As a neuroscientist, I might argue that that phrase and the issues behind it are way more nuanced than the how certain politicians like to use it.
Special endnote Due to some recent shifts in my career, Dr. Simon Says Science will be expanding the content that I write about. Addiction and neuroscience will still be prominently featured but I plan to delve into a variety of other topics that I find interesting and sharing opinions that I think are important. I hope you will enjoy the changes! Thanks very much!
The CDC has released important information on dealing with the prescription opioid pain medication and heroin epidemic. Opioids are a class of drugs that include pain medications such as morphine, oxycodone, hydrocodone, methadone, fentanyl and others and the illegal drug heroin. I’ve spoken a great deal about this problem in various other posts (see here herehere and especially here and here). Just to summarize some of most disturbing trends: the US is experiencing a surge in deaths due to overdose on opioids (overdoses/year due to opioids are now greater than fatalities from car crashes), virtually all demographics (age groups, income levels, gender, race) are affected, and many people addicted to opioid pain pills transition to heroin and as such, a huge increase in heroin abuse is also occurring; teenagers and adolescents are especially hard hit. The CDC’s report, released on Friday, March 18 provides a thorough review of the clinical evidence around prescription opioid pain medications and makes 12 recommendations to help control the over-prescription of these powerful drugs in attempt to reduce the amount of overdose deaths and addiction.
I finally got around to reading the whole thing and am happy to summarize its main analyses and findings. While the report is intended for primary health care providers and clinicians, the report’s findings are important for anyone suffering from short or long-term pain and the risks vs benefits posed by opioids.
But before I dive into the meat of the report, I wanted to clarify an important issue about addiction to prescription opioids. A false narrative exists that those suffering from addiction are “drug seekers” and it is this group of people that is duping doctors in prescribing them too many opioids while good patients that take opioids as directed are not over dosing or becoming addicted. It’s important to remember that opioids are so powerful anyone that takes them runs the risk of overdosing or becoming addicted after repeated use. Most people suffering from addiction and overdoses during the current prescription opioid epidemic are people that used opioids medically and not for recreation. This is true for youths prescribed opioids for a high-school sports injury, and older patients prescribed opioids for chronic back pain, and many other “regular” people. The CDC released this report to help fight back against the over-prescription of opioids and the severe risks that accompany their use. Doctors and patients alike need to be aware of the risks vs benefits of opioids if they decide to use them for pain therapy.
The CDC’s report had three primary goals:
Identify relevant clinical questions related to prescribing of opioid pain medications.
Evaluate the clinical and contextual evidence that addresses these questions
Prepare recommendations based on the evidence.
Two types of evidence were used in preparation of the report: direct clinical evidence and indirect evidence that supports various aspects of the clinical evidence (contextual evidence). Studies included in the analysis ranged from high quality randomized control studies (the gold standard for evaluating clinical effectiveness) to more observational studies (not strong, direct evidence but useful information nonetheless).
The report identified five central questions regarding the concerns over opioids:
Is there evidence of effectiveness of opioid therapy in long-term treatment of chronic pain?
What are the risks of opioids?
What differences in effectiveness between different dosing strategies (immediate release versus long-acting/extended release)?
How effective are the existing systems for predicting the risks of opioids (overdose, addiction, abuse or misuse) and assessing those risks in patients?
What is the effect of prescribing opioids for acute pain on long-term use?
Based on a close examination of the clinical evidence from a number of published studies, the CDC found the following answer to these questions.
There is no evidence supporting the benefits of opioids at managing chronic pain. Opioids are only useful for acute (less than 3 days) pain and for cancer pain or end-or-life pain treatment.
Opioids have numerous risks such as abuse and addiction, overdose, fractures due to falling in some older patients, car crashes due to impairments, and other problems. The longer opioids are used the greater these risks.
There is no difference in effectiveness between immediate release opioids and long-acting or extended release formulation. The evidence suggests the risk for overdose is greater with long-acting and extended-release opioids.
No currently available monitoring methods or systems are capable of completely predicting or identifying risk for overdose, dependence, abuse, or addiction but severak methods may be effective at helping to evaluate these risk factors.
The use of opioids for treating acute pain increases the likelihood that they will be sued long-term (most likely because of tolerance and dependence).
The CDC also examined what they called contextual evidence or studies that didn’t directly answer the primary clinical questions but still provided valuable, if indirect, information about treatment of pain with/without opioids.
Non-medication based therapies like physical therapy, exercise therapy, psychological therapies, etc. can be effective at treating chronic pain for a number of conditions.
Non-opioid pain medications such as acetaminophen, NSAIDs, Cox-2 inhibitors, anti-convulsants, and anti-depressants (in some instances) were also effective in treating chronic pain for various conditions and have fewer dangers than opioids.
Long-acting opioids increase the risk for overdose and addiction. Higher doses of opioids also increase the risk for overdose.
Co-prescription of opioids with benzodiazepines greatly increases the risk of overdoses.
Many doctors are unsure of how to talk to their patients about opioids and their benefits vs risks and most patients don’t know what opioids even are.
The opioid epidemic costs billions of dollars in medical and associated costs. Its estimated costs due to treatment of overdose alone is $20.4 billion.
Many other findings and important pieces are information were reported but too many to list here.
Based on all results of the analysis the CDC came up with 12 recommendations in three broad categories. I’ll briefly discuss each recommendation.
Category 1: Determining when to initiate or continue opioids for chronic pain.
Recommendation 1: Non-pharmacologic (medication-based) therapy and non-opioid pharmacologic therapy are preferred for chronic pain.
The risks of overdose and addiction from long-term use of opioids is very high and benefits for actually treating pain are very low for most people. Therefore, other safer and more-effective treatments should be use first. The discussion of the risks vs benefits needs to be made clear by the patient’s doctor.
Recommendation 2: Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function
Opioids should be used for the shortest amount of time possible but if used for a long-term treatment, at the lowest effective dose.
If a patient suffers from an overdose or seems as if dependence or addiction is developing, a patient may need to be tapered off of opioids.
Recommendation 3: Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy.
The risks are high for the use of opioids and it is necessary for doctors to keep their patients informed about these risks.
Doctors should be “be explicit and realistic about expected benefits from opioids, explaining that while opioids can reduce pain during short-term use, there is no good evidence that opioids improve pain or function with long-term use, and that complete relief of pain is unlikely.”
Category 2: Opioid selection, dosage, duration, follow-up, and discontinuation.
Recommendation 4: When starting opioid therapy, clinicians should prescribe immediate-release opioids instead of extended-release or long-acting opioids.
There appears to be no difference in effectiveness at treating pain between the different types of opioids but the long-acting opioids come with a greater risk for overdose and dependence.
Long-acting opioids should be reserved for cancer pain or end-of-life pain.
It’s important to note that “abuse-deterrent” does not mean that there is no risk for abuse, dependence, or addiction. These types of formulations are generally to prevent intravenous use (shooting up with a needle) but most problems with opioids occur as a result of normal, oral use.
Recommendation 5: When opioids are started, clinicians should prescribe the lowest effective dosage.
The higher the dose the greater the risk. A low dose may be sufficient to control the pain without risk for overdose or the development of dependence.
Opioids are often most effective in the short-term and may not need to be continued after 3 days.
If dosage needs to be increased, changes in pain and function in the patient should be re-evaluated afterwards to determine if a benefit has occurred.
Patients currently on high-dose long-term opioids for chronic pain may want to consider tapering down their dosage.
Tapering opioids can be challenging can take a long-time due to the physical and psychological dependence. Tapering should be done slowly to and the best course of dosage should be determined specifically for the patient.
Recommendation 6: Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed.
Evidence suggests that using an opioid for acute pain can start a patient down a path of long-term use. This should attempted to be avoided by using a low dose if opioid is selected to treat acute pain.
Acute pain can often be effectively managed without opioids with non-medication-based therapies (like exercise, water aerobics, physical therapy, etc.) or non-opioid medications (like acetaminophen or NSAIDs).
Recommendation 7: Clinicians should evaluate benefits and harms with patients within 1-4 weeks of starting opioid therapy for chronic pain or of dose escalation.
Opioids are most effective for the first three days and possible up to a week. If long-term therapy is decided upon, treatment should regularly be reassessed and reevaluated (at least every 3 months for long-term therapy).
Category 3: Assessing risks and addressing harms of opioid use.
Recommendation 8: Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone.
Specific risk factors for the specific condition that patient is using opioids for should be considered when developing the treatment plan.
Naloxone blocks the effects of opioids and can immediately revive someone that has experienced an overdose. Naloxone should be offered to patients if a patient is using opioids at high-dose for long-term therapy or previously suffered an overdose.
Recommendation 9: Clinicians should review the patient’s history of controlled substance prescription using state prescription drug monitoring program (PDMP) data to determine whether a patient is receive opioid dosages or dangerous combinations that put him or her at risk for overdose.
PDMPs are state-run databases that collect information on controlled prescription drugs dispensed by pharmacies and in some states, physicians too.
While the clinical evidence was unclear if PDMPs were accurate at predicting overdose or addiction, the contextual evidence supported that “most fatal overdoses were associated with patients receiving opioids from multiple prescribers and/or with patients receiving high total daily opioid dosage.”
PDMP should be consulted before beginning opioid therapy and during the course of treatment if used for long-term therapy and this data should be discussed with the patient.
However, PDMP data must be used cautiously as some patients are turned away from treatment that would otherwise have benefited.
Recommendation 10: (not a general recommendation but to be considered on a patient-by-patient basis) When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Urine drug tests can reveal information about potential risks due to combinations with other drugs not reported by the patient (e.g. benzodiazepines, heroin).
Urine testing should become standard practice and should be done prior to starting opioids for chronic therapy.
Clinicians should make it clear that testing is intended for patient safety and is not intended to deprive the patient of therapy unnecessarily.
Recommendation 11: Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
Strong evidence suggests that many overdoses occurred in patients prescribed both benzodiazepines and opioids. The two should never be prescribed together if at all possible.
Recommendation 12: Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid abuse disorder (addiction).
Many patients using opioids for chronic pain now may have become physically and psychologically addicted to them and should be offered treatment (estimated at 3-26% of patients using opioids for chronic pain therapy).
Methadone and buprenorphine are proven, safe, and effective-treatments that retain patients in treatment and that satisfy an opioid addict’s cravings, prevent relapse to abusing opioids/heroin, and allow the patient to live a normal life (read my blog post on methadone).
Behavioral therapy/individual counseling in combination with medication-based treatment may improve positive benefits of treatment even further.
However, access to these medications can be extremely limited in some communities due to availability (methadone is restricted to clinics and clinicians need certification in order to prescribe buprenorphine) or cost (treatment often is not covered by insurance).
Urine testing or PDMP data may help to reveal if a patient has become addicted and if so, treatment should be arranged.
In Summary, the main takeaways from the report are:
Opioids are associated with many risks such as overdose, abuse, dependence, addiction, and others (e.g. fractures from falling or car-crashes due to impairment).
No evidence exists that opioids are effective for treatment of chronic pain (with the exception of cancer and end-of-life pain).
Opioids are most effective for short term (3-7 days) and in immediate-release formulations.
Non-medication based therapies and non-opioid medications are preferred for treatment of chronic pain.
Doctors need to clearly explain the risks vs benefits of opioid therapy with their patients.
If decided as the best course of action for a particular patient, opioid therapy needs to be repeated re-evaluated to make sure it is still working to alleviate pain.
The prescription drug monitoring programs are useful tools that should be consulted prior to beginning therapy in order to help determine a patient’s history with opioids and risk for abuse or overdose.
Naloxone should be made available to patients using opioids for long-term therapy in order to prevent possible overdoses.
Access to medication-based treatments (methadone or buprenorphine) for dependent individuals should be provided.
In 1995 Purdue pharmaceuticals released OxyContin (oxycodone, one of the most common prescription opioid pain medications) and launched an enormous push for doctors to use opioids as the primary treatment for chronic pain. The enormous surge in in prescriptions of oxycodone (500% increase from 1999-2011) followed this marketing campaign. One of the most disturbing aspects revealed by the CDC’s report is that despite this surge in prescriptions, there is a complete lack of data on the effectiveness of opioids for long-term chronic pain therapy.
To be fair though, “Big Pharma” is not the sole culprit in this crisis. One argument is that pharma was responding to the need of clinicians for an increased demand by patients for management of chronic pain. It is very disturbing though that the push for the use of opioids for long-term management was initiated without any supporting evidence. This is another example of how medicine must be guided by evidence-based principles and not on personal beliefs and values or medical tradition and culture.
It’s important to remember that some patients do tolerate opioids well and these patients may find them beneficial at treating their chronic pain condition. The guidelines do stress frequent reevaluation of the benefits vs risks of opioids and for some patients benefits will outweigh the risks.
Finally, the CDC’s guidelines are not legally binding. These are recommendations and not laws or regulations. This means no doctors are not legally required to comply with any of the CDC’s recommendations. Hopefully some or all of these recommendations will be formalized into formal laws and regulations because many of them are extremely important in regulating these powerful and potentially dangerous drugs.