In a new commentary in the New England Journal of Medicine (NEJM), authors of the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (Guideline) advise against misapplication of the Guideline that can risk patient health and safety.
CDC commends efforts by healthcare providers and systems, quality improvement organizations, payers, and states to improve opioid prescribing and reduce opioid misuse and overdose. However, some policies and practices that cite the Guideline are inconsistent with, and go beyond, its recommendations. In the NEJM commentary, the authors outline examples of misapplication of the Guideline, and highlight advice from the Guideline that is sometimes overlooked but is critical for safe and effective implementation of the recommendations.
CDC is raising awareness about the following issues that could put patients at risk:
- Misapplication of recommendations to populations outside of the Guideline’s scope. The Guideline is intended for primary care clinicians treating chronic pain for patients 18 and older. Examples of misapplication include applying the Guideline to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing post-surgical pain.
- Misapplication of the Guideline’s dosage recommendation that results in hard limits or “cutting off” opioids. The Guideline states, “When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should… avoid increasingdosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.” The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.
- The Guideline does not support abrupt tapering or sudden discontinuation of opioids. These practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids. In addition, policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.
- Misapplication of the Guideline’s dosage recommendation to patients receiving or starting medication-assisted treatment for opioid use disorder. The Guideline’s 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. The Guideline strongly recommends offering medication-assisted treatment for patients with opioid use disorder.
The Guideline was developed to ensure that primary care clinicians work with their patients to consider all safe and effective treatment options for pain management. CDC encourages clinicians to continue to use their clinical judgment, base treatment on what they know about their patients, maximize use of safe and effective non-opioid treatments, and consider the use of opioids only if their benefits are likely to outweigh their risks.
The Guideline includes guidance on management of opioids in patients already receiving them long-term at high dosages, including advice to providers to:
- maximize non-opioid treatment
- empathetically review risks associated with continuing high-dose opioids
- collaborate with patients who agree to taper their dose
- if tapering, taper slowly enough to minimize withdrawal symptoms
- individualize the pace of tapering
- closely monitor and mitigate overdose risk for patients who continue to take high-dose opioids
Patients may encounter challenges with availability and reimbursement for non-opioid treatments, including nonpharmacologic therapies (e.g., physical therapy). Efforts to improve use of opioids will be more effective and successful over time as effective non-opioid treatments are more widely used and supported by payers.
CDC developed the Guideline to be practical and created clinical tools to help primary care providers help patients manage pain more effectively and safely, while mitigating the potential risks of prescription opioids when needed. CDC has also created specific resources on tapering, dosage, and appropriate application of the Guideline such as:
CDC continues to help inform and improve clinicians’ ability to offer safer, more effective care based on the best available science. As part of that process, CDC is evaluating the adoption, use, and public health impact of the Guideline and its related resources.
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES