MAY 17, 2022
The update to the 2016 “CDC Guideline for Prescribing Opioids for Chronic Pain” continues the agency’s stance that opioids are not a first-line therapy for chronic pain, or even acute pain in some cases. Nonopioid and nonpharmacologic treatments are advocated for in more overt language.
But the addition of language recognizing that clinical judgment should be relied upon more strongly and removal of recommended limits on opioid prescribing have earned the document the most attention. While the CDC maintained that the prescribing limits in the original guideline were voluntary, the consensus from pain clinicians was the limits were often misinterpreted as hard caps, leading to severe unintended consequences in the form of an undertreatment of pain that, in some cases, left legitimate pain patients in such distress they contemplated death or died by suicide.
“The 2016 guidelines were highly restrictive in regards to days of opioids for acute pain and arbitrary thresholds for total MME [morphine milligram equivalents] recommended that failed to highlight the clinical context in which some patients may need increased doses,” said David Dickerson, MD, the section chief for pain medicine at the NorthShore University HealthSystem in Chicago, and chair of the American Society of Anesthesiologists’ Committee on Pain Medicine. “These were then leveraged as a standard of care and hardwired into some states’ laws despite that not being the case.”
The result, he said, was legitimate pain patients who were on existing opioid regimens—and in many cases benefiting from them—being tapered to lower doses or taken off the medications completely by physicians who did not want to to be noncompliant with the guideline recommendations that had become law in some states.
Six years later, the CDC appears to acknowledge that a return to a time when clinical judgment was relied upon is needed, stating in a press statement upon the release of the proposed update that “the guideline recommendations are voluntary and are not intended to be applied as inflexible standards of care or replace clinical judgement or individualized, patient-centered care.” It added that the guideline is “intended to be a clinical tool to improve communication between providers and patients and empower them to make informed, patient-centered decisions related to safe and effective pain care.”
In the new version, much has changed for the better, starting with the ability to make exceptions for challenging cases, adding that those exceptions must still be accompanied by clinical vigilance, Dickerson said.
“MME limits and days-of-therapy limits are replaced with recommending discussion of risks and benefits,” he said of the revised guidance. “Acute, subacute and chronic pain are better delineated, as are the recommendations for continuing opioid therapy for patients already receiving such treatment.”
The updated guidance also provides better evidence-based explanations of what settings and situations the recommendations are appropriate, Dickerson said.
“These guidelines specify that they do not apply to inpatient or emergency department care, as well as are not meant for the treatment of patients with sickle cell disease, end-of-life care, palliative care or cancer care. They also specify that they apply to all clinicians, including oral health providers,” he said.
Still, the new guidance brings with it glaring clinical omissions, said Dickerson, such as failing to address interventional pain medicine as a nonopioid treatment option, and a lack of discussion on consensus-based clinical guidelines for postoperative and chronic pain management.
“The document spends immense effort on discussing risks and benefits of opioids but fails to truly move the needle towards optimizing pain care as a whole,” he said. “This is evident in the failure to include any discussion of neurostimulation, radiofrequency ablation and minimally invasive interventions for spinal stenosis.
“As a pain specialist, the initiation and/or escalation of opioids by clinicians who do not fully understand the other nonopioid options for a chronic painful condition is a major concern, and remains an issue for the field that neither these nor the previous guideline addresses,” Dickerson added.
“This comment period provides another critical opportunity for diverse audiences to offer their perspective on the draft clinical practice guideline.We want to hear many voices from the public, including people living with pain and the healthcare providers who help their patients manage pain,” said Christopher M. Jones, PharmD, DrPH, MPH, the acting director for the National Center for Injury Prevention and Control, and a captain in the U.S. Public Health Service, in endorsing the need for public comment. “The ultimate goal of this clinical practice guideline is to help people set and achieve their personal goals to reduce their pain and improve their function and quality of life. Getting feedback from the public is essential to achieving this goal.”
Clinicians like Dickerson are not concerned that the update will bring with it a more cavaliere opioid prescribing attitude, but acknowledged that the pressure is squarely on clinicians to use their best judgment in all aspects of pain care, especially opioid prescribing.
“Physicians still must be responsible for their patients’ care and outcomes despite these pivots,’” he said. “This document should not open up the door for clinicians to feel like opioid safety or risk has changed, just that the risk mitigation will need to occur from clinical oversight and individual risk assessment. The risk profile of opioids should keep them as non–first-line agents for both acute and chronic pain.”
Although the CDC’s efforts to make the guideline work for more people the second time around are clearly appreciated by many in the pain medicine field, some are frustrated that this might not have been the case when the guideline was first written prior to 2016.