Applause for the CDC opioid guideline authors

Applause for the CDC opioid guideline authors
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For several years, we have been a nation focused on prescription opioid reduction. In recognition of data showing steep increases in overdose rates and the need to advise prescribing clinicians, the Centers for Disease Control (CDC) issued the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.  

This week, the CDC published in the "New England Journal of Medicine" a key clarification of the 2016 opioid prescribing guideline. The clarification acknowledges that misapplications of the guideline and efforts to de-prescribe opioids and reduce addiction and other health risks for some Americans has backfired for many and exposed them to newer and possibly graver health risks.

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The 2016 CDC guideline was less controversial in content than it was in practice. Its recommendations were intended for a narrow audience — primary care providers — and for use in a limited scope —managing long-term chronic pain. Further, it advised if opioids were prescribed, clinicians should prescribe the lowest effective dose and monitor carefully for benefit and risks when considering dose increase.

While cautions were advised, medical decision-making was intended to remain in the hands of the trained medical professionals. CDC clarified this critical point today: dose thresholds were designed only for the initiating of opioid therapy, and were never intended to justify forcing patients taking long-term opioids down to these thresholds, or being denied these medications at all.     

However, health-care organizations and states have cited the CDC guideline as a basis for policies and laws that extend well beyond its intended purpose. The guideline has been wrongly cited to substantiate proposed dose-based opioid prescribing policies that fail to account for the medical circumstances of the individual patient.

For example, Oregon’s Medicaid and Washington’s Bree Collaborative are two current statewide policy recommendation groups that misapply the 2016 CDC guideline and cite it as a basis for mandated opioid tapering in patients taking long-term opioid prescriptions, despite the CDC authors noting that (1) the creation of “hard limits or ‘cutting off’ opioids” is not supported by the CDC, and (2) that it “does not suggest discontinuation of opioids” for patients taking high-dose opioids and supports reduction in cases of patient consent to do so. As such, proposals to force taper select patient groups to a pre-specified dose limit, or completely off their pain medication(s) stand in direct opposition with the CDC recommendations.  

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Additionally, reports of depression, suffering and patient suicides during forced opioid tapering increased at alarming rates and advocacy groups began curating patient suicide registries. An international stakeholder community published a letter calling for federal action to protect patients from abrupt and forced opioid tapering harms.

Shortly after, Human Rights Watch published a report documenting patient harms from forced opioid tapering. More than 300 health-care professionals and three former U.S. drug czars who advised past presidents on national drug policy called on the CDC to address the misapplication of the guideline. CDC nobly responded to these and underscored the original language of the guideline while strongly discouraging current and proposed policies and practices that fall outside its scope.

As a pain psychologist, scientist and author, I have spent 15 years helping people use strategies to help them minimize their need for pain medications. However, the assumption that "less opioids is always better, for everyone," is just as flawed as assuming that an opioid is right for everyone; absolutes in either direction confer risk. The CDC statement makes clear that opioid reduction is not right for everyone, and in so doing, reflects the individual differences in the experience and treatment of pain.  

I am leading national research on patient-centered, voluntary prescription opioid tapering (funded by the Patient-Centered Outcomes Research Institute). We partner with patients, do not mandate tapering or a final dose. I believe this approach not only honors the patient’s own experience, it mirrors the CDC clarifications.  

The CDC clarification is important for acute pain patients, too, a population that the guideline was never intended to address. Multiple policies have placed limits on post-surgical opioid prescribing, thereby placing some patients at risk for increased pain after surgery — itself a risk factor for the persistence of pain. We must be mindful that attempts to reduce addiction and other risks does not contribute to increased and lasting pain.  

How do we treat pain better and reduce health risks? We need flexible policies that provide meaningful access to comprehensive pain care and do not myopically focus on opioid dose reduction policies. We must provide pain education to all health-care clinicians and implement the National Pain Strategy.

We need systems and resources to characterize each person’s individual risks and needs and address those with patient centered approaches and evidence-based treatments. Now that the CDC has answered the call for careful protections for patients needing and taking opioids, the imperative is for organizations and policy makers to align their actions with this federally-issued guidance. 

Beth Darnall, Ph.D. is an associate professor at Stanford University School of Medicine. Follow her on Twitter: @bethdarnall.