CDC Issues Opioid Guidelines for 'Doctor-Driven' Epidemic

March 15, 2016

The Centers for Disease Control and Prevention (CDC) today issued final recommendations for prescribing opioids for chronic pain to combat an epidemic of prescription overdoses that claims 40 lives a day.

When it comes to most chronic-pain patients, the CDC's advice seemingly boils down to one word — don't.

"The science of opioids for chronic pain is clear," said CDC Director Tom Frieden, MD, MPH, in a news teleconference today. "For the vast majority of patients, the known, serious and all too often fatal risks far outweigh the unproven and transient benefits, and there are safer alternatives."

Accordingly, the first of the agency's 12 recommendations states that opioids are not first-line therapy for chronic pain, and that clinicians should first consider nonopioid pain relievers or nonpharmacological options such as exercise and cognitive behavioral therapy. Other recommendations include conducting a urine test before opioid therapy, starting at the lowest dose possible and avoiding doses of 90 morphine milligram equivalents (MME) or more, prescribing immediate-release as opposed to longer-acting opioids, and limiting treatment for acute pain to usually no more than 7 days.

The nonbinding guidelines do not apply to patients who are receiving palliative care or end-of-life care, or treatment for active cancer. The CDC tailored the recommendations for primary care clinicians, who account for roughly half of opioid prescriptions.

Dr Frieden said clinicians play a key part in reducing the rate of addiction and death associated with these drugs.

"The prescription overdose epidemic is doctor-driven," he said. "It can be reversed in part by doctors' actions."

How Strong Is the Evidence?

The final recommendations remain mostly unchanged from a draft version released last December, despite strong objections from several major medical societies in the interim. They pointed to a dearth of strong evidence supporting individual recommendations, such as the adequacy of nonopioid and nonpharmacological therapies to counter chronic pain. On that point, the American Medical Association (AMA) and the American Pain Society noted that the widespread lack of reimbursement for nonpharmacological therapies deters clinicians from ordering them.

Dr Frieden said that the agency based its guidance on the best available research on chronic pain, which is "not as robust as we'd like." The CDC will refine its recommendations as more evidence emerges, he said, but in the meantime, "we must act now."

The CDC has discussed with physicians and patient groups the problem of little or no insurance coverage of nonpharmacological treatments of chronic pain, added Dr Frieden. "I'm encouraged by the progress we've seen in a variety of insurance programs."

Debra Houry, MD, MPH, director of the CDC's National Center for Injury Prevention and Control, said that the new guidelines "can inform a lot of future changes."

Some medical societies also had faulted the first version of the guidelines for setting numerical thresholds, as in avoiding dosages of 90 MME per day, or suggesting that most nontraumatic pain unrelated to major surgery usually doesn't warrant more than 3 days of treatment. In a January letter to the CDC, the American Academy of Pain Medicine, for example, said that the dosage recommendation should not refer to any "arbitrary dose." And the group asked that the rule of thumb for duration be extended to 2 weeks.

The final versions of these recommendations preserves the numbers, but with some tweaks. Clinicians should avoid doses of 90 MME per day or more, or else "carefully justify a decision" to prescribe that amount. And the recommendation on duration reached this compromise wording: "Three days or less will often be sufficient, more than seven days will rarely be needed."

Dr Houry said that while some clinicians urged the CDC to leave out the numbers, other clinicians wanted to keep them, and even advocated for lower dosages and durations. "These are guidelines, not regulations," she added.

Initial response from organized medicine to the final CDC recommendations was mixed. The American College of Physicians came out in support of them, with Thomas Tape, MD, chair-elect of its Board of Regents, calling the guidelines "an important document" in a news release.

In contrast, the AMA was "largely supportive." Patrice Harris, MD, chair-elect of the AMA's board of directors, cited qualms with, among other things, the "evidence base for some recommendations," insurance coverage limitations for nonpharmacological treatment, "and the potential effects of strict dosage and duration limits on patient care."

"If these guidelines help reduce the number of deaths resulting from opioids, they will prove to be valuable," said Dr Harris in a news release. "If they produce unintended consequences, we need to mitigate them. They are not the final word."

Gregory Terman, MD, PhD, the president of the American Pain Society, told Medscape Medical News that the CDC's final recommendations contain improvements over the original version, giving physicians more flexibility to operate around "specific numbers." Dr Terman was one of 10 experts convened by the agency in January to review the proposed guidelines.

"Primary care doctors wanted and needed some advice on this problem area," said Dr Terman, professor and director of pain medicine research at the University of Washington in Seattle. "The CDC has done a good job in trying to make a good-faith effort to produce guidelines that help people to avoid overprescribing, but not restrict [patients] who really benefit from opioids on an individual basis."

Dr Oz Calls In

During today's news teleconference, the CDC received a phone call from someone normally not considered part of the news media.

The caller was Mehmet Oz, MD, host of the eponymous television show and lightning rod for considerable controversy over his product endorsements and views on alternative medicine. Identifying himself as from The Dr. Oz Show, Dr Oz asked what the average patient should say to a clinician who offers to prescribe an opioid for chronic pain.

"What do you recommend that they push back on?" he asked. "How would they…articulate their reticence to taking an opiate?"

"That's a great question," replied Dr Frieden. "I would first say, 'Is this necessary? What are the alternatives? What are the risks? What's the dosage? And can you guarantee that this is going to relieve my pain and not risk getting me addicted?' "

Deborah Dowell, MD, MPH, a senior medical advisor in the CDC's National Center for Injury Prevention and Control, said she agreed with Dr Frieden 100%, but posed some additional questions.

"How long do you anticipate that I'm going to be taking this," Dr Dowell said, "[and] what do we hope to accomplish? What should be our goals…and how are you going to know if you accomplish them?"

The final CDC recommendations on opioid prescribing and related information, such as a prescriber checklist, are available on the agency's website.


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