In what appears to be a step forward, the recommendations take into account the nuances of prescribing opioid-based pain medication
By Jason Langendorf
The Centers for Disease Control and Prevention (CDC) last week released proposed updates to its guidelines for opioid prescriptions, marking a shift from rigid dosage recommendations toward a more flexible, patient-centric approach.
The existing CDC guidelines, which were put in place in 2016, reflect concerns about the nation’s growing opioid epidemic and the risks of overprescribing opioid-based pain medication. But the specificity baked into those recommendations had a chilling effect on prescribers, leading to some chronic pain patients having their dosage reduced to ineffective levels or being cut off from medication altogether.
The new guidelines are subject to a 60-day public comment period—essentially, an all-points review of the drafted updates—before undergoing any amendments and full adoption. Thus far, the proposed guidelines have received mostly positive feedback from experts.
“I think that the CDC is recognizing that the original guidelines, while very clearly in 2016 were stated as recommendations and guides, were applied in a much more rigid manner that was not person-centered,” says Stephen Delisi, MD, medical director of Hazelden Betty Ford Foundation’s training and consultation division. “And although that approach resulted in a reduction in the overall prescribing of opioids for individuals suffering from pain, it has not resulted in a reduction in the heart of our ongoing opioid crisis.”
Opioid prescriptions have been in decline since 2012, and dropped sharply after the release of the CDC’s 2016 guidelines. But the opioid crisis continues unabated, with overdose deaths hitting record highs month after month. Meanwhile, patients whose treatment was adversely affected by the rigidity of the CDC guidelines and clinicians’ fears of overprescription may finally get some relief from the organization’s new updates.
The Proposed CDC Opioid Guidelines
As stated in the proposal document, “The clinical practice guideline is intended to achieve the following: Improved communication between clinicians and patients about the risks and benefits of pain treatment, including opioid therapy for pain; improved safety and effectiveness for pain treatment, resulting in improved function and quality of life for patients experiencing pain; and a reduction in the risks associated with long-term opioid therapy, including opioid use disorder, overdose and death.”
Stefan Kertesz, MD, professor of medicine at University of Alabama at Birmingham, helped lead a national petition in 2019 that prompted the CDC to issue a clarification of its previous guidelines. Kertesz thinks the proposed 2022 updates are an improvement, but he also believes that even more can be done.
Kertesz says insurers and payers should collaborate on establishing new pay models for comprehensive pain assessment. He advocates for better training for clinicians, particularly primary care practitioners, who often have minimal time to assess a complex problem. The Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services, Kertesz says, would do well to reevaluate policies that limit access to non-medication pain care—a significant consideration in light of the updated CDC guidelines stating that “nonopioid therapies are preferred for subacute and chronic pain.”
“I think the tendency still is to discuss opioids pro or con. But we have to broaden how we explain that issue.”—Stefan Kertesz, University of Alabama at Birmingham
First and foremost, Kertesz says, the field must become more contextual in its decision-making. “I really think that the central issue in complex disability decisions are often related to the context of the patient’s life and history,” he says. “And right now, I think the tendency still is to discuss opioids pro or con. But we have to broaden how we explain that issue.”
At the same time, Kertesz says the progress made from the private draft initially drawn up in the summer of 2021 to the CDC’s current proposed guidelines “addressed a lot of concerns in a good way, and we have to commend them for that.”
Delisi, like Kertesz, is hopeful that all involved are moving in the right direction.
“Fundamentally, the issue has been one of not assessing, nor treating adequately, substance use disorders at the level of primary care providers within the communities in which people live,” Delisi says. “And that’s where the field is heading. I think these guidelines can contribute to improving the person-centered nature of that approach.”
Top photo: Nick Fewings