Updated November 3, 2022 at 4:22 pm ET
The Centers for Disease Control and Prevention have issued new guide for doctors on how and when to prescribe opioids for pain. Released Thursday, this renews the agency’s 2016 recommendations that some doctors and patients have criticized for promoting a culture of austerity around opioids.
CDC officials say doctors, insurers, pharmacies and regulators have sometimes misapplied previous guidelines, causing significant harm to some patients, including “untreated or undertreated pain, severe withdrawal symptoms, worsening of the results of pain, psychological distress, overdose and [suicide]”, according to the updated guide.
The 100-page document and its top recommendation serve as a roadmap for prescribers navigating the thorny topic of pain management, including advice on managing pain relief after surgery and managing pain conditions. chronic, estimated to affect one in five people in the united states
The 2016 guidelines proved immensely influential in policymaking, fueling the push by insurers, state medical boards, politicians and federal law enforcement to curb opioid prescribing.
The consequences, doctors and researchers say, are hard to overstate: an untreated pain crisis. Many patients with severe chronic pain saw their long-standing prescriptions quickly reduced or stopped altogether, sometimes with dire consequences, including suicide or overdose, as they turned to the tainted supply of illicit drugs.
Federal agencies had tried to correct course, making it clear that previous voluntary guidelines were not intended to become strict policy or law. But doctors and patient advocates were also hopeful that the CDC’s updated guidelines would undo some of the unintended consequences of previous guidance.
This was clearly on the minds of CDC health officials when they announced the new clinical guidelines on Thursday.
“The guideline recommendations are voluntary and are intended to guide shared decision-making between a doctor and a patient,” said Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control and co-author of the guidelines. updated guidelines, during a press conference. report, “It is not intended to be implemented as absolute limits of policy or practice by physicians, health systems, insurance companies, government entities.”
The change in perspective is evident in all the new guidelines, says Dr Samer NarouzePresident of the American Society for Regional Anesthesia and Pain Medicine.
“You can tell that the culture around the 2016 guidelines was just to reduce opioids, that opioids are bad,” he says. “It’s the opposite here, you can feel that they care more about patients who are living with pain. It’s more about relieving their pain and suffering.”
A new focus on individualized care
Opioid prescribing began to decline in 2012, and that trend continued after the 2016 guidelines were released. There is widespread agreement that opioids should be used with caution due to the risks associated with addiction and overdose. But today, the most overdose deaths they are not due to prescription opioids, but to fentanyl and other illicit drugs.
Fighting the street drugs that drive today’s overdose crisis “is not the goal of this guideline,” Jones said, describing those efforts as a separate but parallel “whole of government” approach. Instead, the focus is on patients with pain. “The goal is to improve pain, function and quality of life [for patients] while reducing the misuse, diversion and consequences of prescription opioid misuse,” Jones said.
The new guidelines still emphasize that opioids should not be the gold standard treatment in many cases, pointing to evidence that other treatments and approaches are often comparable in improving pain and function. However, the recommendations make it clear that the guideline should not replace clinical judgment and that clinicians can work with patients who are in pain, even if it means continuing opioids.
“Each patient is a different story and deserves individualized attention,” says Narouze. “This is what I like most about the new guidelines.”
more work to do
While the voluntary guidelines are a welcome step, their impact largely depends on how state and federal agencies and other authorities respond to them, he says. leo beletskyprofessor of law and health sciences at Northeastern University and director of the Health Action Laboratory in Justice there.
“The CDC needs to be much more proactive than just putting out this update and trying to reverse some of the misunderstandings of the previous version,” he says. The agency needs to work with other federal agencies, she says, including Health and Human Services and the Drug Enforcement Administration, as well as law enforcement to implement these guidelines.
For example, Beletsky points out how the definition of high-dose opioid use, described as 90 or more milligram equivalents of morphine daily in the 2016 recommendations – was used to establish legal limits. “The  the guideline itself was clear that it wasn’t a clear line rule,” he says, “but it became a de facto label, separating appropriate from inappropriate prescribing,” he says. And this led to the law enforcement in some states to use the limit “like a sword to go after prescribers.
These doses and limits, set without much scientific evidence to back them up, have had a chilling effect on doctors, he says. Cindy Steinberga patient advocate for the US Pain Foundation.
“Most of the people I know, and I know a lot of people living with chronic pain, have already stopped taking their medications. Doctors are very afraid to prescribe them.” From Steinberg’s perspective, the new CDC guidelines are still too restrictive and won’t make much of a difference for patients who have already been harmed.
Specific dose and duration limits are out
The most important changes in the new guideline are presented in the form of 12 bullet points that set out the general principles related to prescribing.
Unlike the 2016 version, those findings no longer include specific limits on the dose and duration of an opioid prescription a patient can take, though later in the document it warns against prescribing above a certain threshold. The new recommendations also explicitly warn doctors not to rapidly reduce or stop prescriptions for patients who are already taking opioids, unless there are indications of a life-threatening problem.
“I think they are very understanding and compassionate,” he says. Dr Antje Barreveld, medical director of Pain Management Services at Newton Wellesley Hospital. “Those arbitrary marks of what is acceptable and not acceptable is what got us in trouble with the 2016 guidelines, because it left this blanket cut for our patients and that’s not what pain control is about.”
The direction of reducing opioids when possible still raises some concerns for clinicians as Stefan Kerteszprofessor of medicine at the University of Alabama at Birmingham.
“I would emphasize that when you take a stable patient and reduce [their prescription], you’re involved in an experiment,” says Kertesz. “Dose reduction is just an uncertain intervention that sometimes helps and sometimes kills the patient. So I would rather they had said, ‘Look, this is an uncertain intervention.’
However, he adds that the strength of the new guidance is its repeated emphasis that agencies, law enforcement and payers should not use a specific dose to enforce a one-size-fits-all approach.
Unraveling Rigid Opioid Prescribing Policies
It’s unclear whether the new guidance will translate into substantive changes for patients struggling to manage their pain.
Many patients are currently unable to find treatment, following the 2016 guidelines, says Barreveld, because doctors are wary of prescribing.
She recalls a recent case when an elderly patient of hers suffered from severe arthritis in his neck and knees. “I recommended to the primary care doctor that he start low-dose opioids, and the primary care doctor said ‘no,'” says Barreveld. “What happened? The patient was put in the hospital, thousands of dollars a day for eight days, and what was she discharged with? Two or three opioid pills a day.”
Previous guidelines led to restrictions on prescribing being codified as policy or law. It’s not clear that those rules will be rewritten in light of the new guidelines, although they state that they “are not intended to be implemented as absolute limits on policy or practice.”
“That’s a good idea, and it will have absolutely no effect unless three major agencies take action immediately,” says Kertesz. “The DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, all three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality metrics and legal research.”
The ability to coordinate and repair the damage that arose from the 2016 guidance depends on the leadership of the CDC, an agency whose credibility and authority have taken a hit during the COVID-19 pandemic, Beletsky says. Still, the agency has learned from the criticism and the damage from the latest round of guidance. “So my hope is that the CDC is now better equipped and prepared to take the guidance and translate it to the ground level,” she says.
The quality of life of many patients living with chronic pain will depend on it.