Certain policies and practices about opioids and chronic pain patients have been misapplied and do not reflect the 2016 recommendations, said guideline authors Deborah Dowell, MD, MPH, and Tamara Haegerich, PhD, both of the CDC in Atlanta, and Roger Chou, of Oregon Health and Science University in Portland.
“Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with and often go beyond its recommendations,” they wrote in a New England Journal of Medicine commentary.
The inconsistencies — highlighted in a consensus panel report by the American Academy of Pain Medicine(AAPM) Foundation — include inflexibly applying opioid dosage and duration thresholds and encouraging hard limits and abrupt tapering, they noted.
“The panel also noted the potential for misapplication of the recommendations to populations outside the scope of the guideline,” Dowell and colleagues wrote. “Such actions are likely to result in harm to patients.”
In the commentary, the guideline authors reviewed specific actions that could harm patients, notably:
Forcing hard limits of opioid doses
The guideline states that “Clinicians should … avoid increasing dosage to ≥90 morphine milligram equivalents (MME)/day or carefully justify a decision to titrate dosage to ≥90 MME/day,” the authors stated. “This statement does not address or suggest discontinuation of opioids already prescribed at higher dosages, yet it has been used to justify abruptly stopping opioid prescriptions or coverage.”
“The CDC based the recommendation on evidence of dose-dependent harms of opioids and the lack of evidence that higher dosages confer long-term benefits for pain relief,” they added. “However, we know little about the benefits and harms of reducing high dosages of opioids in patients who are physically dependent on them.”
Abruptly tapering or suddenly stopping opioids
Chronic pain patients who are able to taper their opioid use successfully may have a lower risk of overdose, but others may find it challenging and may face withdrawal symptoms, increased pain, or unrecognized opioid use disorder, “and if their dosages are abruptly tapered may seek other sources of opioids or have adverse psychological and physical outcomes,” Dowell and colleagues wrote.
“The guideline offers guidance for caring for patients who are already taking opioid dosages of 90 MME or more per day long term, including guidance on when tapering the dose might be appropriate, the importance of empathetically reviewing risks associated with continuing high-dose opioids, collaborating with patients who agree to taper their dose, maximizing non-opioid treatment, and tapering slowly enough to minimize withdrawal symptoms,” they continued. The guideline does not support stopping opioid use abruptly, they added.
Applying recommendations to patients outside the guideline’s scope
The guideline does not apply to patients in active cancer treatment or who are experiencing acute sickle cell crises or post-surgical pain, the authors clarified. Similarly, dose limits recommended in the guideline do not apply to the use of medication-assisted treatment for patients with opioid use disorder.
Acknowledging the guideline has been misapplied or overinterpreted is an important first step, noted Kurt Kroenke, MD, of the Indiana School of Medicine in Indianapolis, first author of the AAPM Foundation’s consensus panel report.
“However, the onerous and overly restrictive prescribing policies created by legislatures and payers that have led to unintended harm for the subset of pain patients benefiting from opioids will take longer to roll back,” Kroenke told MedPage Today. “Also, the burdens, fears, and stigma attached to appropriate opioid prescribing instilled in many clinicians will be more difficult to reverse.”
While the AAPM consensus panel supported many parts of the 2016 guideline, “the best laid plans of mice and men may have gone by the wayside,” said Charles Argoff, MD, AAPM Foundation president, in an interview with MedPage Today.
“What’s missing in this discussion is the real acknowledgement of lives lost, not due to opioid harm, but due to the cessation of opioid prescribing,” Argoff added.
The CDC is evaluating the effect of the guideline and will update recommendations when new evidence is available, Dowell and colleagues noted. The agency is funding systematic reviews about the effectiveness of opioid and other acute and chronic pain treatments to identify research priorities and determine when evidence gaps are addressed. “Until then, we encourage implementation of recommendations consistent with the guideline’s intent,” they wrote.
LAST UPDATED 04.25.2019
New England Journal of Medicine