In 2016 the Centers for Disease Control heeded a call to action by publishing CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (Dowell, et al., 2016). This document was created to provide a better framework for primary care providers to manage chronic pain and give guidance for when to consider prescribing opioids safely and thoughtfully.
Why? In 2012, it was identified that health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills (Paulozzi, et al., 2012). Opioid prescriptions per capita increased 7.3% from 2007 to 2012, with opioid prescribing rates increasing more for family practice, general practice, and internal medicine compared with other specialties (Levy, et al., 2015). But more to the point of the public health crisis, individuals were dying at increasing numbers as the direct and indirect results of opioid use. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States (CDC, 2016).
What did the 2016 guidelines do well, and where did they miss the boat?
The recommendations are grouped into three areas for consideration:
- Determining when to initiate or continue opioids for chronic pain.
- Opioid selection, dosage, duration, follow-up, and discontinuation.
- Assessing risk and addressing harms of opioid use.
The 2016 guidelines created an environment where healthcare providers were more thoughtful and mindful about their opioid prescribing, especially in primary care settings, where historically clinicians had not had much formal training in chronic pain management. The guidelines introduced the importance of multimodal care in chronic pain management and established a structure of recommendations to opioid prescribing in primary care. Finally, the guidelines put forth education about the public health concern with indiscriminate opioid prescribing.
Unfortunately, at the CDCs own admission, the recommendations put forth in the 2016 document were misapplied (Dowell, et al., 2022):
- Becoming a matter and vehicle for public policy
- Created a backlash of deprescribing, patient abandonment and abrupt discontinuation of opioids
- Took away clinicians’ autonomy to treatment patients individually
- Became a by default “standard of care” for all prescribing situations without taking into account special populations (cancer, specialty care, post-surgical, hematology, etc.)
Fast forward 2022
Late in 2022 the Centers for Disease Control resolved to rectify the public and professional outcry over the challenges faced with the 2016 guidelines, while maintaining the core values of public safety, by publishing CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 (Dowell, et al., 2022). These changes being made on “new evidence having 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.”
What do the 2022 guidelines provide us that the 2016 did not?
- Recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.
- The guideline more clearly addresses the following 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
4) assessing risk and addressing potential harms of opioid use.
Focus on communication between clinicians and patients about:
- Benefits and risks of pain treatments, including opioid therapy
- The effectiveness and safety of pain treatment
- To improve function and quality of life for patients with pain
- Specifically reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death; special focus on risk mitigation.
Where do we go from here?
Irrespective of government “recommended” guidelines, clinicians MUST keep in mind what is best and safest for the individual patient in the given situation. Practicing team based multidisciplinary care in pain management, with a focus on multimodal treatments will result in the most consistent outcomes long-term. Guidelines, whether put forth by respected government agencies, specialty societies, researcher organizations or respected individuals, are meant to assist individual decision making based on the unique situation and circumstances and should never be used as constraints with legal consequences especially when following “guidelines” without thoughtful critical thinking may result in patient harm. Now the question begs, does it all really come down to the Hippocratic oath” “Primum non nocere”. Or more correctly, “I will apply the regimens of treatment according to my ability and judgment for the benefit of my patients and protect them from harm and injustice,” (Retas, 2004).
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References:
CDC. Multiple cause of death data on CDC WONDER. Atlanta, GA: US Department of Health and Human Services, CDC; 2016. https://wonder.cdc.gov/mcd.html.
Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: https://dx.doi.org/10.15585/mmwr.rr7103a1
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: https://dx.doi.org/10.15585/mmwr.rr6501e1
Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med 2015;49:409–13.
Paulozzi LJ, Mack KA, Hockenberry JM. Vital signs: variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. MMWR Morb Mortal Wkly Rep 2014;63:563–8.
Retsas S. Treatment at Random: The Ultimate Science or the Betrayal of Hippocrates? JCO. 2004. VOLUME 22 NUMBER 24 5005-5008. DOI: 10.1200/JCO.2004.01.044