CDC’s opioid guideline misapplied by doctors and insurers to detriment of pain patients, 300+ experts say

More than 300 healthcare professionals are urging the Centers for Disease Control and Prevention (CDC) to clarify its opioid guideline, which they say is hurting chronic pain patients.

In a March 6  letter, the group, calling itself Health Professionals for Patients in Pain (HP3), said the guideline issued by the CDC in 2016 is being misapplied by doctors and insurers to the detriment of pain patients—even driving some chronic pain patients to suicide.

The letter was signed by many prominent medical experts, including three former White House "drug czars" who served in the Obama, Clinton and Nixon administrations.

“We urge the CDC to issue a bold clarification about the 2016 guideline—what it says and what it does not say, particularly on the matters of opioid taper and discontinuation,” the group wrote in the letter, which was also sent to leaders of the House Committee on Energy and Commerce and the Senate Committee on Health Education Labor and Pensions. 

The healthcare professionals also urged the CDC to evaluate the impact of the guideline by talking directly with a wide range of patients and caregivers. They urged the CDC to engage epidemiologic experts to investigate reported suicides by patients who have seen their opioids prescriptions discontinued or cut back, as well as increases in illicit opioid use.

The CDC issued a new guideline for primary care doctors three years ago in response to the country’s opioid epidemic and fears physicians were overprescribing the painkillers to patients. The guideline directed primary care clinicians to prescribe treatments other than opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.

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At the time, some physicians worried the guideline would make it difficult for patients who suffer with chronic pain to get the medications they need. While prescriptions have fallen since the CDC released the guideline, it has had some detrimental consequences, the medical experts said in the letter.

“Within a year of guideline publication, there was evidence of widespread misapplication of some of the guideline recommendations,” they wrote. Notably, many doctors and regulators incorrectly interpreted the guideline to believe the CDC established a threshold of 90 morphine milligram equivalents as a daily dose limit.

Clinicians prescribing higher doses, pharmacists dispensing them and patients taking them came under suspicion, the group said.

Doctors need to understand the guideline does not endorse mandated involuntary dose reduction or discontinuation of opioids, they said.

The guideline has resulted in payer-imposed payment barriers and pharmacy chain demands for patient medical charts or plans to taper opioid doses as a precondition for filling prescriptions, the letter said. Quality agencies have imposed high-stakes metrics and physicians face legal or professional risks, the experts said.

“Taken in combination, these actions have led many healthcare providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care,” they wrote.

Those signing the letter said adverse experiences for patients are mostly anecdotal, but they described them as concerning. “Patients with chronic pain, who are stable and, arguably, benefiting from long-term opioids, face draconian and often rapid involuntary dose reductions. Often, alternative pain care options are not offered, not covered by insurers, or not accessible,” they said. Other patients are pushed to undergo addiction treatment or invasive procedures, such as spinal injections, whether or not they are clinically appropriate.

“Consequently, patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use,” the letter said. Other patients have experienced preventable hospitalizations or deterioration of their medical condition in part because insurers, regulators and other parties have interpreted the 90 morphine milligram equivalents as a daily threshold for opioids.

“Under such pressure, care decisions are not always based on the best interests of the patient,” they said.