CDC finalizes guideline aimed at limiting opioids for chronic pain

The Centers for Disease Control and Prevention (CDC) on March 15 finalized a voluntary guideline that officials hope will cause primary care physicians to proceed more cautiously in prescribing opioids for patients with chronic pain. While the CDC reiterated in a press release this week that the guideline followed “a rigorous scientific process using the best available scientific evidence,” some groups representing physicians continue to express serious misgivings about the document and its potential effects.

Addiction Professional reported in January that even though compliance with the guideline is not mandatory, its publication in mid-December led to a flood of public comments.

The chair-elect of the American Medical Association's (AMA's) board of directors, Patrice A. Harris, MD, said in a statement upon formal release of the CDC guideline this week, “While we are largely supportive of the guidelines, we remain concerned about the evidence base informing some of the recommendations, conflicts with existing state laws and product labeling, and possible unintended consequences associated with implementation... .” These concerns on the AMA's part include whether patients wll have sufficient access to the non-pharmacologic treatment options that the CDC suggests are more effective than opioids in addressing chronic pain.

Others reacted much more positively to the final release of the CDC guideline, which is limited to prescribing in outpatient primary care settings for chronic pain lasting longer than three months and not in the context of palliative care. USA Today quoted Andrew Kolodny, executive director of Physicians for Responsible Opioid Prescribing, as saying, “For the first time, the federal government is communicating clearly that the widespread practice of treating common pain conditions with long-term opioids is inappropriate. The CDC is making it perfectly clear that medical practice needs to change because we're harming pain patients and fueling a public health crisis.”

Guiding principles

The CDC emphasizes that within the guideline's 12 recommendations, three principles for improving patient care stand out:

• Non-opioid treatments are preferred for chronic pain not in the context of active cancer, palliative or end-of-life care.

• When the decision to prescribe opioids for chronic pain is made, the lowest possible effective dosage should be used in order to mitigate risk of dependence and overdose.

• Prescribers should exercise caution at all times and should monitor patients closely.

The guideline covers treatment initiation, dosing, duration of treatment, tapering, and risk assessment and mitigation. CDC director Thomas Frieden, MD, MPH, was direct in communicating the urgency of the guideline's release.

“More than 40 Americans die each day from prescription opioid overdoses, we must act now,” Frieden said. “Overprescribing opioids—largely for chronic pain—is a key driver of America's drug-overdose epidemic.”

The CDC also has developed materials, including a decision checklist, to assist providers in implementing the guideline's recommendations.