COMMENTARY

Consequences of the CDC's Opioid Guideline for Chronic Pain

Charles E. Argoff, MD

Disclosures

June 06, 2019

This is Dr Charles Argoff, professor of neurology at Albany Medical College and director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York. I imagine that we would each agree that it's challenging to treat a person experiencing severe, chronic pain. That's in general, but also specifically, when it comes to treating that person or considering that person for chronic opioid therapy.

Since the publication of the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain in 2016,[1] numerous formal and informal reports of treatment decisions regarding opioid treatment of chronic pain made by physicians and other prescribers, and changes in payer policies, have been noted, with significant adverse consequences to the person in pain—unfortunately—not uncommon.

I have personally been told by people experiencing chronic pain that the change in treatment was made by their physician because he or she told the patient that he or she was forced to do so as a consequence of the CDC guideline.

For example, on January 18, 2019, in an article in the Los Angeles Times, The Clampdown on Opioid Prescriptions Is Hurting Pain Patients,[2] the author, who had experienced chronic pain and had been previously treated successfully with chronic opioid therapy, describes another person's experience in which a physician advised that that person's opioid dose had to be cut by 75% "to comply with federal guidelines." The physician was citing the CDC guideline, which in fact did not state that. In that article, the author noted, "The CDC needs to revise its guidelines to recommend that physicians do not abandon pain patients or engage in forced tapering."

On April 24, 2019, three of the authors of the CDC guideline published a perspective, No Shortcuts to Safer Opioid Prescribing, in the New England Journal of Medicine.[3] The authors advised against the misapplication of the guideline, noting that doing so can risk patient health and safety. The authors noted efforts by healthcare providers and systems, quality improvement organizations, payers, states, and others to improve opioid prescribing and reduce opioid misuse and overdose. They also noted that some policies and practices that cite the guideline are not consistent with its recommendations.

Awareness was specifically raised in this perspective about the issues that could put patients at risk, including misapplication of recommendations to populations outside of the guideline's scope. The guideline is intended for primary care physicians and clinicians treating chronic pain in patients 18 years of age and older. Examples of misapplication that were cited in this perspective include application of the guideline to active cancer treatment patients, people experiencing sickle cell crises, or people experiencing postsurgical pain.

Awareness was raised to the misapplication of the guideline's dosage recommendations, which results in hard limits or cutting off opioids. The guideline states and explains that when opioids are started, clinicians should prescribe the lowest effective dose and they should try to avoid increasing beyond a threshold of 90 morphine milligram equivalents per day, or they should carefully justify a decision to titrate a dosage higher than that.

In this perspective, the authors acknowledge that the recommendation statement in the CDC guideline does not suggest discontinuation of opioids already prescribed at higher doses. They also state that the guideline does not support abrupt tapering or sudden discontinuation of opioids, as we just saw was the perspective published in the Los Angeles Times.

This, as they acknowledge, can result in severe opioid withdrawal symptoms, pain, psychological distress, and—this is written in the perspective—some patients might seek out other sources of opioids.

Another area of misapplication of the guideline involves dosage recommendations to patients receiving or starting medication-assisted treatment for opioid use disorder. The guideline recommendation about dosage applies to use of opioids in the management of chronic pain, not to the use of medication-assisted treatment for opioid use disorder. This was made clear in the perspective.

The CDC guideline was developed to try to ensure that primary care clinicians work with their patients to consider all safe and effective treatment options for pain management. In their perspective, the authors note that patients may encounter challenges related to the availability and reimbursement of nonopioid treatments and nonpharmacologic treatments, such as physical therapy. Essentially, trying to incorporate nonopioid and multidisciplinary approaches may be challenging.

The perspective also cited a multidisciplinary consensus panel report published in Pain Medicine earlier this year. The members and authors of the report included authors of the CDC guideline. This report is entitled Challenges With Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report.[4]

In this report, the authors noted that deployment of the CDC guideline has raised substantial clinical and public policy challenges. They also recognized that the CDC anticipated implementation challenges and was committed to reevaluating the guideline for intended and unintended effects on clinician and patient outcomes. Certainly, the perspective that was published in April in the New England Journal of Medicine addresses much of what I just stated.

The consensus panel identified implementation challenges, including application of dosage ceilings and prescription duration guidance, failure to appreciate the importance of patient involvement in decisions to taper or discontinue opioids, barriers to diagnose and treat opioid use disorder, and impeded access to recommended comprehensive multimodal pain care.

Furthermore, the panel noted that policymaking and regulatory bodies may misapply guideline recommendations without flexibility, and sometimes without full awareness of what the guideline contains. This was a different consensus panel, but the content was very much in line with what three of the CDC authors published in the perspective in the New England Journal of Medicine on April 24.

A different group, Health Professionals for Patients in Pain, commented on their website, commending the three authors of the CDC guideline for publishing their perspective, and noting that the authors make it clear that the guideline did not urge and does not support policies and practices that mandate dose reduction or discontinuation, even though the guideline does support individualized assessment of the potential value of tapering doses.[5]

This group noted that the table is now set for necessary revision to the policies instituted across the country that utilize mandates, strong incentives, and implied threats in ways that have been harmful to patients. This is also very important.

The publication and the perspective on the CDC guideline provide a welcome step forward. What comes next is unknown. To the best of my knowledge, there is no clear way to account for the harm to people experiencing chronic pain whose chronic opioid treatment regimen was abruptly and/or inappropriately changed as a result of such misapplication or misapplications. Such harm, to the best of my knowledge, included loss of life in some reported instances. How and when will such suffering end?

The CDC guideline was developed to guide a specific group of providers regarding the reduction of risks associated with chronic opioid therapy prescribed to a specific group of people in pain, regardless of intent. The misapplication of this guideline has hurt people in pain. We cannot currently quantify how many people have been hurt or to what extent they have been hurt.

One can only hope that with the perspective written by three CDC guideline authors, the publication of the consensus panel report (whose authors included other CDC guideline authors) describing the challenges with implementing the CDC guideline, and other efforts underway, we will be able to move forward in a manner that would be patient centric, focusing on identifying and ensuring access to the most effective pain care for each person in pain.

As three of the authors of the CDC guideline state in their perspective, such care could include treatment with chronic opioid therapy and there should be no one-size-fits-all approach to such treatment.

I'm Dr Charles Argoff from Albany Medical Center and Albany Medical College. I hope you've enjoyed this perspective.

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