CDC Clarifies: Okay to Prescribe Opioids for Cancer Pain

Attempts to Quell Denials of Reimbursement

Nick Mulcahy

April 09, 2019

The Centers for Disease Control and Prevention (CDC) has issued a clarification letter that states the agency does not want to deny clinically appropriate opioid therapy to cancer and sickle cell disease patients, particularly those who are undergoing cancer treatment and survivors with chronic pain.

The unusual issuance was addressed to three major cancer organizations who met with the CDC last fall to discuss concerns about the impact of the agency's Guideline for Prescribing Opioids for Chronic Pain.

The American Society of Clinical Oncology (ASCO), American Society of Hematology (ASH), and National Comprehensive Cancer Network (NCCN) were all worried that patients were being denied pain drugs or reimbursement as a result of the guideline, which is aimed at primary care providers.

The CDC clarification is "critically important," said Clifford Hudis, MD, chief executive officer, ASCO, in a press statement.

He explained that the CDC's guideline "clearly states that it is not intended to apply to patients during active cancer and sickle cell disease treatment," but that "many payers have been inappropriately using it to make opioid coverage determinations for those exact populations."

The CDC letter, signed by Deborah Dowell, MD, chief medical officer, National Center for Injury Prevention and Control, says the guideline "is not intended to deny any patients who suffer from chronic pain from opioid therapy as an option for pain management."

Instead, the CDC's intention is to ensure that clinicians and patients "consider all safe and effective treatment options."

The CDC's letter explains which patients with cancer their guideline addresses: cancer survivors who have chronic pain and have completed treatment, are in remission, or are under "cancer surveillance only."

The benefits and risks of all treatments, including opioids, must be carefully considered, says the CDC clarification letter. And treatment plans for pain should be revisited regularly, the agency says.

The CDC letter also specifically addresses "select groups of cancer survivors" with persistent pain because of past cancer or cancer treatment and defers treatment decision-making guidance to survivor guidelines from ASCO (2016) and the NCCN (2018), both of which were published after the CDC guideline. "Such guidelines provide useful guidance on unique considerations for use of opioids for pain control in cancer survivors," reads the CDC clarification letter.

"Our guidelines help clinicians to assess the risk of inappropriate substance use, while still ensuring people with cancer don't suffer unnecessary, severe pain," said Robert Carlson, MD, chief executive officer, NCCN, in the press statement.

However, at the recent NCCN annual conference, meeting attendee Rene Rubin, MD, director, Hahnemann Hospital Cancer Center, Philadelphia, Pennsylvania, suggested there is now another problem getting opioids for patients with cancer who need them: prescriber fears.

"A lot of my colleagues will not write a script for analgesics. They tell patients to go to a pain clinic," she told Medscape Medical News, adding that this is costly and inconvenient for patients with cancer.

Also at the meeting, Judith Paice, PhD, RN, director, Cancer Pain Program, Northwestern University, Chicago, Illinois, echoed this observation: "We are seeing more fear from healthcare professionals regarding prescribing of opioids — fear that their licenses will somehow be affected."

In its new clarification letter, the CDC said it "encourages physicians to continue to use their clinical judgment and base treatment on what they know about their patients, including the use of opioids."

The American Cancer Society Cancer Action Network (ACS CAN) reported that since the CDC issued its 2016 guideline, cancer patients, survivors, and others living with serious chronic pain have experienced greater difficulty getting needed pain medication.

In a survey, about half of cancer patients (48%) and those with other serious illnesses (56%) said that their physician-indicated pain treatments were limited by laws, guidelines, or insurance coverage, according to ACS CAN.

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