The fine line between overprescribing and underprescribing opioids must be decided on a case-by-case basis, according to an updated guideline released by the Centers for Disease Control and Prevention (CDC) yesterday.
The new guidance avoids numerical dose limits and caps on length of treatment for chronic pain patients. recommends how and when to prescribe opioids, and describes harms and benefits.
The updated guideline suggests that individuals “with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations.”
The recommendation hinges on good communication between providers and patients, in which the benefits and risks of opioids are discussed. It’s meant to “improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy; including opioid use disorder; overdose, and death.”
Richard Stefanacci, the chief medical officer at the Jefferson College of Population Health at Thomas Jefferson University, tells Fierce Healthcare that “change takes a great deal of time and must come from multiple sources.”
Stefanacci believes that the updated CDC guidance will have no impact in the short run. “The market has already pushed to have restrictions on opioid use,” says Stefanacci. “These restrictions have been widespread by medical societies, state regulators, and health systems. As a result, further changes are unlikely shortly.”
The guidelines represent the latest iteration of trying to find the right balance and updating a 2016 recommendation that took aim at overprescribing opioids but may have gone too far in that it may have led to too quickly weaning patients off the medications and not offering appropriate pain relief for those who really need it.
The CDC says it updated the guideline after clinical evidence emerged about the misapplication of the 2016 guideline in terms of “different tapering strategies and rapid tapering associated with patient harm, challenges in patient access to opioids, patient abandonment and abrupt discontinuation of opioids.”
The CDC’s updated recommendation infers that the concern about overprescribing opioids in the 2016 version might have led to misinterpretation among providers about best practices and swung the pendulum too far in the other direction. That led to “rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment (previously referred to as medication assisted treatment), duration limits by insurers and pharmacies, and patient dismissal and abandonment.”
The 2016 recommendation had been applied to patients suffering from cancer and on palliative care who should have had more painkillers.
The 2016 recommendation also focused on the prescribing practices of primary care physicians, who prescribe about 37% of opioid prescriptions. “This clinical practice guideline expands the scope to additional clinicians,” the updated guideline states, including pain medicine clinicians (8.9% of opioid prescriptions) and dentists (8.6% of opioid prescriptions).
“Pain medicine and physical medicine and rehabilitation clinicians prescribe opioids at the highest rates, followed by orthopedic and family medicine clinicians,” the CDC states. “Thus, expanding the scope to outpatient opioid prescribing can provide evidence-based advice for many additional clinicians, including dentists and other oral health providers, clinicians managing postoperative pain in outpatients, and clinicians providing pain management for patients being discharged from emergency departments.”
Opioid use should begin only after other therapies have been attempted. “Nonopioid therapies are preferred for subacute and chronic pain,” the updated guideline states. “Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.”
The American Academy of Pain Medicine, which represents physicians who specialize in pain management, applauded the CDC’s move, but in its response suggested how the guidelines might be strengthened that including an executive summary that includes the five guiding principles and 12 recommendations that the AAPM says are currently buried in the 211-page document. In addition, the group raises concerns that the 2016 recommendations will still find their way back into practice. It suggests rescinding the 2016 document altogether, rather than updating it.
The AAPM wants the CDC to “explicitly highlight factors involved in misapplication of the 2016 guideline by third-party payers, health care organizations, government jurisdictions, medical boards, pharmacy benefit plans (PBMs) and pharmacy chains in wrongly codifying inflexible maximum opioid dosages and days’ supply into policy and legislation and publicly advocate that those misapplications be revisited and polices and plans appropriately updated.”