Earlier version created harm after being twisted by outside forces

“Pain affects the lives of millions of Americans every day and improving pain care and the lives of patients with pain is a public health imperative,” stated the Centers for Disease Control and Prevention (CDC) in November upon updating its guideline on prescribing opioids for pain treatment. The November changes are the first time the guideline has been updated since it was issued in 2016.

The CDC clarified in strong terms that the earlier guideline had been misinterpreted in ways that harmed pain patients (seeThrowing the baby out with the bathwater”). Instead of focusing on specific medication dosages—guidance which had been misapplied—the update reviews general principles. It addresses how to reduce health risks associated with both opioids and non-opioid options. The agency also cited scientific advances.

The CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022 provides 12 recommendations in four areas:

  1. determining whether or not to initiate opioids for pain,
  2. selecting opioids and determining opioid dosages,
  3. deciding duration of initial opioid prescription and conducting follow-up and
  4. assessing risk and addressing potential harms of opioid use.

According to the CDC, the guideline is in accord with “the primary prevention pillar of the HHS [Health and Human Services] Overdose Prevention Strategy—supporting the development and promotion of evidence-based treatments to effectively manage pain.” The first recommendation notes that non-opioid medications are at least as effective as opioids for many common types of acute pain.

“Patients with pain should receive compassionate, safe, and effective pain care. 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,” said Christopher M. Jones, PharmD, DrPH, MPH, acting director of the CDC’s National Center for Injury Prevention and Control.

The CDC stated that the guideline should help clinicians and patients collaborate on individualized treatment options and “not be used as an inflexible, one-size-fits-all policy or law or applied as a rigid standard of care or to replace clinical judgment.”

There is a section looking at substance use disorders under Recommendation 8 (evaluating the risk of opioid-related harm). Recommendation 12 explores pain management for people living with an opioid use disorder. That recommendation states that, “Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.” There’s also a statement that the effect of stigma as a treatment barrier for people with substance use disorder is a research area to be explored. According to the guideline, “Although stigma can reduce the willingness of persons with opioid use disorder to seek treatment, opioid use disorder is a chronic, treatable disease from which persons can recover and continue to lead healthy lives.”

The CDC’s Clinical Practice Guideline for Prescribing Opioids for Pain is at cdc.gov/opioids/healthcare-professionals/prescribing/guideline.

From the guideline

The following highlights are taken directly from the guideline (references can be found in the original):

“Pain is one of the most common reasons adults seek medical care in the United States.”

“Pain is a complex phenomenon influenced by multiple factors, including biologic, psychological, and social factors.”

“Approximately one in five U.S. adults had chronic pain in 2019 and approximately one in 14 adults experienced ‘high-impact’ chronic pain, defined as having pain on most days or every day during the past 3 months that limited life or work activities.”

“Pain, especially chronic pain, can affect almost every aspect of a person’s life, leading to impaired physical functioning, poor mental health, and reduced quality of life, and contributes to substantial morbidity each year.”

“Pain might go unrecognized, and some persons (e.g., members of marginalized racial and ethnic groups; women; older persons; persons with cognitive impairment; persons with mental and substance use disorders, sickle cell disease, or cancer-related pain; and persons at the end of life) can be at risk for inadequate pain treatment.”

“Chronic pain often co-occurs with behavioral health conditions, including mental and substance use disorders. Patients with chronic pain also are at increased risk for suicidal ideation and behaviors.”

“Because of the clinical, psychological, and social consequences associated with pain, including limitations in activities, lost work productivity, reduced quality of life, and pervasive stigma, it is essential that clinicians have the training, education, guidance, and resources to provide appropriate, holistic, and compassionate care for patients with pain.”

“Opioids can be essential medications for the management of pain; however, they carry considerable potential risk.”

“In addition to the potential risks to patients, prescribed opioids have the potential for diversion and nonmedical use among persons to whom they were not prescribed. In the United States, opioid prescribing increased fourfold during 1999–2010; this increase was paralleled by an approximately fourfold increase in overdose deaths involving prescription opioids during the same period and increases in prescription opioid use disorder. In addition to the increased overall volume of opioid prescriptions during this period, how opioids were prescribed also changed; opioids increasingly were prescribed at higher dosages and for longer durations, prescribing behaviors associated with opioid use disorder and overdose. The limited evidence of long-term effectiveness of opioids for chronic pain, coupled with risks to patients and to persons using prescription opioids that were not prescribed to them, underscored the importance of reducing inappropriate opioid prescribing while advancing evidence-based pain care to improve the lives of persons living with pain.”

“Although not the intent of the 2016 CDC Opioid Prescribing Guideline, design and implementation of new laws, regulations, and policies [seemed] to reflect its recommendations. For example, since 2016, consistent with SUPPORT Act requirements, some state Medicaid programs have used the guideline and other resources to promote nonopioid options for chronic pain management. Approximately half of all states have passed legislation limiting initial opioid prescriptions for acute pain to a ≤7-day supply, and many insurers, pharmacy benefit managers, and pharmacies have enacted similar policies. At least 17 states have passed laws requiring or recommending the coprescription of naloxone in the presence of overdose risk factors, such as high dosages of opioids or concomitant opioid pain medications and benzodiazepines.”

“Since release of the 2016 CDC Opioid Prescribing Guideline, new evidence has emerged on the benefits and risks of prescription opioids for both acute and chronic pain, comparisons with nonopioid pain treatments, dosing strategies, opioid dose-dependent effects, risk mitigation strategies, and opioid tapering and discontinuation. This evidence includes studies on misapplication of the 2016 CDC Opioid Prescribing Guideline, benefits and risks of different tapering strategies and rapid tapering associated with patient harm, challenges in patient access to opioids, patient abandonment and abrupt discontinuation of opioids, a seminal randomized clinical trial comparing prescription opioids to nonopioid medications on long-term pain outcomes, the association of characteristics of initial opioid prescriptions with subsequent likelihood for long-term opioid use, and the small proportion of opioids used by patients compared with the amount prescribed to them for postoperative pain.”

A summary of the guideline in the CDC’s November 4 Morbidity and Mortality Weekly Report at bit.ly/MMWR-2022-11-04. Read the guideline at cdc.gov/opioids/healthcare-professionals/prescribing/guideline.

For more information

Additional materials associated with the guideline (in Spanish and English) for people living with chronic pain, addressing how to reduce health risks associated with both opioids and non-opioid options are available. Go to cdc.gov/opioids/patients. The page includes the toll-free number to the National Helpline of the Substance Abuse and Mental Health Services Administration (SAMHSA), 1-800-662-HELP (4357), along with a link to the agency’s Behavioral Health Treatment Services Locator. SAMHSA’s locator for physicians who can prescribe buprenorphine can be found at findtreatment.gov.

Throwing the baby out with the bathwater

“Although some laws, regulations, and policies that appear to support recommendations in the 2016 CDC Opioid Prescribing Guideline might have had positive results for some patients, they are inconsistent with a central tenet of the guideline: that the recommendations are voluntary and intended to be flexible to support, not supplant, individualized, patient-centered care. Of particular concern, some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations. Such misapplication includes

  • extension to patient populations not covered in the 2016 CDC Opioid Prescribing Guideline (e.g., cancer and palliative care patients),
  • rapid opioid tapers and abrupt discontinuation without collaboration with patients,
  • rigid application of opioid dosage thresholds,
  • application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment (previously referred to as medication assisted treatment),
  • duration limits by insurers and pharmacies, and
  • patient dismissal and abandonment.

“These actions are not consistent with the 2016 CDC Opioid Prescribing Guideline and have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

—From the introduction to the CDC 2022 Clinical Practice Guideline for Prescribing Opioids for Pain.

The guideline addresses racial disparities

“Although substantial opportunity exists for improved pain management broadly across the United States, data underscore opportunities for addressing specific, long-standing health disparities in the treatment of pain. For example, patients who identify as Black or African American (Black), Hispanic or Latino (Hispanic), and Asian receive fewer postpartum pain assessments relative to white patients. Black and Hispanic patients are less likely than White patients to receive analgesia for acute pain. Among Black and White patients receiving opioids for pain, Black patients are less likely to be referred to a pain specialist, and Black patients receive prescription opioids at lower dosages than White patients. Racial and ethnic differences remain even after adjusting for access-related factors, the needs and preferences of patients, and the appropriateness of the intervention. These disparities appear to be further magnified for Black and Hispanic patients who live in socioeconomically disadvantaged neighborhoods. Women might be at higher risk for inadequate pain management, although they have higher opioid prescription fill rates than men at a population level. Geographic disparities contribute to increased use of opioids for conditions for which non-opioid treatment options might be preferred but are less available. For example, adults living in rural areas are more likely to be prescribed opioids for chronic non-malignant pain than adults living in nonrural areas. Although not Hispanic or Latino (non-Hispanic) American Indian or Alaska Native and non-Hispanic White populations have experienced much higher rates of prescription opioid–related overdose deaths than non-Hispanic Black, Hispanic, or non-Hispanic Asian or Pacific Islander populations, application of safeguards in opioid prescribing are disproportionately applied to Black patients. In one study, Black patients were more likely than White patients to receive regular office visits and have restricted early refills. In another study, clinicians were substantially more likely to discontinue opioids if there was evidence of misuse for Black patients compared with White patients. Differentially untreated or undertreated pain as a result of clinician biases persists and demands immediate and sustained attention and action.”

—From the introduction to the CDC 2022 Clinical Practice Guideline for Prescribing Opioids for Pain. See references in the guideline.