CDC Issues Final Guidelines for Opioid Prescribing
With Commentary by Daniel B. Carr, MD
The Centers for Disease Control and Prevention (CDC) has issued recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain. The new guidelines are "intended to improve communication about the benefits and risks, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy," according to a report published online by JAMA.1
According to the CDC, the number of people experiencing chronic pain is estimated at 11.2% of the adult population. As many physicians know, opioids have been prescribed for the management of moderate to severe pain for decades. It is now estimated that approximately 3% to 4% of the adult U.S. population are prescribed long-term opioid therapy.
In 2013, nearly 2 million Americans aged 12 or older either abused or were dependent on opioid drugs, according to the CDC. In that same year, more than 16,000 Americans died from overdoses related to prescription opioid drugs—the height of opioid prescribing.
This rise in opioid abuse and overdose has made primary care clinicians nervous about managing chronic pain patients. Anecdotal reports at various pain conferences covered by Practical Pain Management have noted that many PCP practices are now turning away chronic pain patients as "too difficult" to manage.
In this environment, the CDC announced plans to draft a guideline on prescribing opioids for chronic pain. Those guidelines were officially released on March 15, 2016. The initial draft guidelines were met with sharp criticism from pain specialists and organizations, including the American Academy of Pain Medicine (AAPM), as well as from some legislators, including Senator Elizabeth Warren (D-Mass). In addition, the Food and Drug Administration has released its own action plan to address the opioid epidemic.
In a statement released by AAPM, the association said they cautiously support the efforts of the CDC to address the challenges that often accompany prescribing opioids for chronic non-cancer pain.
“We know that doctors—primary care and pain medicine specialists—are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed," said Dan Carr, MD, President of the AAPM and Professor of Public Health and Community Medicine at Tufts University. "Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients.”
Dr. Carr said that society needs to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH.
"Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences," he said. "We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence. It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately."
How CDC Developed Guidlines
For the development of these recommendations and guideline, which are for non-cancer or palliative care chronic pain patients, the CDC updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs.
"Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology," wrote the agency.
There are 12 recommendations for 3 areas: determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. Among the recommendations:
- Of primary importance, nonopioid therapy is preferred for treatment of chronic pain.
- Opioids should only be used when benefits for pain and function are expected to outweigh risks.
- Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks.
- When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible.
- Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages.
- For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone.
The authors write that to inform future guideline development, more research is needed to fill critical evidence gaps. “Yet given that chronic pain is a significant public health problem, the risks associated with long-term opioid therapy, the availability of effective alternative treatment options for pain, and the potential for improvement in the quality of health care with the implementation of recommended practices, a guideline for prescribing is warranted with currently available evidence.”
They add that the “CDC is committed to evaluating the guideline to identify effects on clinician and patient outcomes, both intended and unintended, and will revisit the guideline to determine if evidence gaps have been sufficiently addressed to warrant an update of the guideline and revise the recommendations in future updates when warranted.”
Practical Pain Management will be following this story as well as reporting on physician responses to the release of the new guidelines. Please feel free to leave your own comments here.