The Centers for Disease Control and Prevention on Thursday issued new guidance for doctors who treat pain patients that reverses a 2016 version used to sharply curtail opioid prescriptions, ultimately leading to devastating results for some pain patients.
The new guidance avoids strict figures on dosage and length of opioid prescriptions, recommends how and when to prescribe opioids, and describes harms and benefits. But the CDC emphasized the recommendations are voluntary and flexible and should not be used to support a one-size-fits-all policy.
The original version was meant for primary care doctors who treat chronic pain patients but ended up being used by states, licensing boards, insurers, pharmacies and others to force millions of Americans to rapidly reduce or discontinue prescription opioids.
Pain patient advocates said the update improves the original version that led to abrupt changes for 8 to 13 million Americans who take opioids to manage pain. But they said prescribers, insurers and others must adopt more nuanced policies to avoid harms such as addiction, suicide and diminishing quality of life.
“The CDC is sending a pretty strong message to all payers, states and health systems that they need to reverse course, that they misapplied the (2016) guideline and they need to change because they’re causing harm,” said Kate Nicholson, executive director and founder of the National Pain Advocacy Center.
What are the new recommendations?
The guidance addresses whether to prescribe opioids for pain, determining dosages, length of initial fills and how and when to follow up with patients.
- Discuss alternative therapies and prescribe the lowest dosage for patients who have not taken opioids before.
- Recommend pain pills for chronic pain patients only if the benefits and ability to do daily tasks outweigh known risks, which can include addiction, overdose and death.
- Discuss risks and benefits, and consider how opioid prescriptions will be discontinued.
- Rely on other therapies and try to gradually lower dosages or discontinue opioids for patients already on higher dosages.
Unless there’s a life-threatening issue such as signs of overdose, doctors should not abruptly discontinue or rapidly reduce opioid dosages, the guidance says.
“Patients with pain should receive compassionate, safe and effective pain care,” said Christopher Jones, acting director of CDC’s National Center for Injury Prevention and Control. “We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life.”
How is it different from the old recommendations?
Under the old recommendation, chronic pain patients complained of being cut off from pills they had taken for months or even years. Some in the middle of cancer treatments, sickle cell disease, or recovering from operations could not get pain medications even though the policy did not focus on these individuals.
The updated guidance has recommendations for those with short-term pain of less than one month, lingering pain of one to three months, and chronic pain of more than three months.
The original guidance stressed that doctors should be careful to avoid daily opioid doses that exceed 90 morphine milligram equivalents. The new version recommends doctors be cautious but does not forbid prescribing daily doses of more than 50 morphine milligram equivalents. If doctors do prescribe that much, the guidance recommends doctors offer overdose education and the overdose-reversal drug naloxone.
How will the CDC monitor the guidance?
While the guidance is voluntary, the CDC will evaluate and monitor how doctors and patients adjust to the new recommendations.
The CDC plans to educate doctors and others if the agency sees evidence people are misinterpreting the guidance or using it as “justification for taking some rigid action that applies to all patients,” Jones said in a call with reporters.
What are the lingering effects of the original guidance?
Studies show more than half of primary care doctors won’t see a patient who takes opioids to manage pain, Nicholson said.
Abruptly tapering or discontinuing opioids increases pain patients’ risk of addiction and suicide. Jones said abrupt tapering “creates a very real risk” for patients, including mental health, thoughts of suicide, or seeking illicit opioids to stave off withdrawal.
After the 2016 guidance, more than half of states passed laws that limited initial opioid prescriptions for acute pain to seven days or less. Many states limited pain pill fills for Medicaid enrollees, and private insurers and pharmacies also curtailed opioid prescriptions. Some states enacted strict limits on doses, prompting doctors to aggressively taper patients who had been on opioids for years, and medical boards sanctioned doctors who ran afoul of the tighter requirements.
After the original guidelines, a non-peer-reviewed survey of more than 3,000 patients found 84% reported more pain and worse quality of life, and 42% said they had considered suicide, according to the CDC.
Do disparities exist among pain patients?
Black patients have lower overdose rates from prescription pain pills than white patients, Latinos and Native Americans, but one study cited by the CDC showed Black patients were more likely than whites to have early refills restricted. Another study showed doctors were substantially more likely to discontinue opioids for Black people compared to white people if they misused pain pills, the CDC said.
Black patients are less likely to be referred to a pain specialist, according to the CDC, and Black patients get lower-dose opioids compared to whites.
Ken Alltucker is on Twitter as @kalltucker or can be emailed at [email protected]