As doctors say they welcome the Centers for Disease Control and Prevention’s (CDC) recent clarification of its opioid guideline, the authors of that guideline said in a new paper that medical professionals had misapplied those recommendations.
Expressing the sentiments of many doctors, the American Medical Association (AMA), the country’s largest physician group, said in a statement Wednesday that it welcomed the CDC’s revised view on the federal opioid guideline, which was originally issued three years ago.
At the same time, the authors of the guideline said in a paper published Wednesday in the New England Journal of Medicine that some doctors and other clinicians had often wrongly implemented the guideline in ways that likely harmed patients.
“Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations,” wrote Deborah Dowell, M.D., and Tamara Haegerich, Ph.D., both of the CDC, and Roger Chou, M.D., of the Oregon Health and Science University in Portland, who were the authors of that 2016 guideline.
Misapplication of the guideline, for instance, resulted in the sudden discontinuation of opioids in patients and in some cases the dismissal of patients from physician practices, said the authors. It was also misinterpreted to apply to patients outside the scope of the guideline, including cancer patients, they said.
Misinterpretation resulted in “inflexible application of recommended dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages,” which the guideline never recommended, they said.
The guideline, issued in an attempt to curb widespread opioid abuse that spiraled into a national epidemic, provided recommendations for primary care physicians and advised them to prescribe treatments other than opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.
A letter authored by Dowell was released publicly April 9 clarifying that the guideline was not intended to deny chronic pain patients relief from opioids and encouraged physicians to use their “clinical judgment” in prescribing the medications.
That was welcome news for doctors, said Patrice A. Harris, M.D., president-elect of the AMA and chair of its Opioid Task Force.
“The AMA appreciates that the CDC recognizes that patients in pain require individualized care and that the agency’s 2016 guidelines on opioids have been widely misapplied. The guidelines have been treated as hard and fast rules, leaving physicians unable to offer the best care for their patients,” Harris said.
The clarification underscores that patients with acute or chronic pain can benefit from taking opioids at doses that may be higher then the guidelines suggest, or thresholds put forward by federal agencies, state governments, health insurance companies, pharmacy chains, pharmacy benefit managers and other advisory or regulatory bodies, she said.
“The AMA continues to urge physicians to make judicious and informed prescribing decisions to reduce the risk of opioid-related harms,” she said, noting a 22% decrease in opioid prescriptions between 2013 and 2017.
“The guidelines have been misapplied so widely that it will be a challenge to undo the damage,” Harris said, adding that the AMA is urging a detailed regulatory review of formulary and benefit design by payers and pharmacy benefit managers to ensure patients have access to both pharmacologic and non-pharmacologic treatments.
The CDC’s clarification that the guideline was not meant to limit access to pain management for patients with cancer or sickle cell disease was welcomed by oncologists, said doctors at the American Society of Clinical Oncology (ASCO). Leaders at ASCO, the National Comprehensive Cancer Network and the American Society of Hematology had written to the CDC asking for that clarification.
Studies have shown that one-third or more patients with cancer and survivors are having difficulty accessing prescribed opioid medications, which has increased markedly since the CDC guideline was issued in 2016, oncologist Ray Page, D.O., and Elizabeth Blanchard, M.D., wrote in a commentary in the Journal of Oncology Practice.
There is a renewed focus on opioid prescribing as the country tackles an ongoing opioid addiction crisis. A new poll found that a third of Americans have been directly touched by the country’s opioid epidemic. The poll by NPR and Ipsos found one in three people have been personally affected, either by knowing someone who has overdosed or knowing someone with opioid addiction, according to an NPR report.
The CDC says more than 200,000 Americans have died from prescription opioid overdoses since the addiction crisis began in the late 1990s.