A Closer Look at the Updated CDC Opioid Guideline

Ahead of his session at the 2024 Cape Cod Symposium on Addictive Disorders, "CDC Opioid Guideline Update: What EVERYONE Needs to Know," the Psychiatry and Behavioral Health Learning Network asked Mark Garofoli, PharmD, MBA, clinical assistant professor and director of experiential learning for the West Virginia University school of pharmacy, a few questions about what these guideline changes mean for addiction treatment.

Dr Garofoli discusses the key changes in the CDC's 2022 Opioid Guideline Update and their impact on clinical practice, highlights the expanded scope of the guidelines to all outpatient settings, the nuanced approach to pain management, and the importance of patient-provider communication when considering opioid therapy. 

For more coverage on the 2024 Cape Cod Symposium on Addictive Disorders, visit the newsroom. 

Psychiatry and Behavioral Health Learning Network (PBHLN): What are the most significant changes in the 2022 CDC Opioid Guideline Update compared to the 2016 guidelines, and how do these changes impact clinical practice?

Mark Garofoli, PharmD, MBA: The most prominent update is the scope expansion from only primary care to all outpatient settings. Quite frankly, that’s huge, yet concurrently a reflection of the observed 2016 original guideline application anyway. Other updates include expanded time frames of including subacute (between acute and chronic); specific pain conditions: stating FDA-approved medications and/or respective guidelines for osteoarthritis, neuropathic pain, fibromyalgia, diabetic peripheral neuropathy, and post herpetic neuropathy (still emphasizing exclusion of palliative care, cancer pain, and sickle cell pain); emphasizing to only gradual taper when appropriate; and updated morphine milligram equivalent (MME) factors for hydromorphone (was 4, now 5), methadone (was incremental, now 4.7), and tramadol (was 0.1, now 0.2), along with a “massaged” discussion on the cautionary threshold level of 50 MMEs/day.

PBHLN: Can you elaborate on the key components of pain management that should be considered before initiating opioid medications, according to the updated guidelines?

Dr Garofoli: Conversations. Discussions with a patient (and perhaps previous/concurrent providers) regarding their “story” including current/past medical history homing in on current and past treatments, diagnoses, and pain origin scenarios. Then progressing the conversation to the risk reduction strategies and best practices of deploying an opioid risk screening and prescription drug monitoring program review within a patient-provider agreement.

PBHLN: What are the key takeaways for clinicians regarding the appropriate utilization of morphine milligram equivalent (MME) in patient care?

Dr Garofoli: Morphine milligram equivalents (MMEs) are an attempt at comparing potency, or risk, of opioids, yet are founded upon the fundamental differences of a medication’s distinct dose-response curves for analgesia and respiratory depression. MME factors are useless until multiplying by the respective opioid dose, as the milligram of one medication is not comparable in and of itself to another medication. The updated CDC opioid guideline recommends “caution” once reaching the threshold of 50 MMEs/day.

PBHLN: How should clinicians adapt their approach to opioid prescribing and pain management to better meet the needs of their patients?

Dr Garofoli: Perhaps Vanilla Ice said it best, “Stop. Collaborate. And Listen.” Ironically, that song lyric best sums it up. Stop, meaning take pause, have conversations as already mentioned. Collaborate, meaning pain management is best served as an interprofessional team utilizing a diverse pain management treatment plan. Listen, as a reminder to all of us clinicians to listen to patients, fellow providers, and guidelines alike; although every recommendation or personal fact (i.e., opinion) may not be genuinely utilized.

PBHLN: What are some best practices for managing chronic pain without relying on opioids, and how can clinicians effectively integrate these practices into their treatment plans?

Dr Garofoli: Diversify. If one utilizes the most potent treatment option every day, then what is one left with when experiencing a “bad day”? I usually reserve that question for discussing acute and as needed utilization of muscle relaxants (as FDA-approved) as compared to continual daily utilization, but it fits opioid discussions as well. If I’m the patient in pain, and you and I undoubtedly have been in the past, we want “all hands on deck”, not just one health care professional, but all of them, along with their respective treatment expertise. 

PBHLN: Is there anything else you would like to share with the Psychiatry & Behavioral Health Learning Network audience?

Dr Garofoli: Opiates is a term referring to what’s in the poppy: morphine, codeine, and thebaine. Opioids refers to the rest of the gang (semi-synthetics and synthetics), yet typically universally refers to all opioids. Thus, let’s redirect all the headlines: it’s an opioid crisis, not an opiate anything. There are little, if any, recent accounts of human beings overdosing on opiates, as heroin and fentanyl are opioids. 

Mark Garofoli, PharmD, MBA, BCGP, CPE, CTTS, is a 2004 graduate from the Pitt School of Pharmacy and a 2008 graduate of the Strayer University MBA program, and is a board-certified geriatric pharmacist (BCGP), certified pain educator (CPE), and certified tobacco treatment specialist (CTTS), with APhA certificate training in immunizations and medication therapy management (MTM).

Dr Garofoli created and coordinated the West Virginia Expert Pain Management Panel, which developed the West Virginia Safe & Effective Management of Pain (SEMP) guidelines. He is currently a clinical assistant professor and director of experiential learning for the WVU school of pharmacy, along with being a clinical pain management pharmacist at the WVU Medicine Center for Integrative Pain Management and Pain Fellowship Faculty for the WVU School of Medicine. Mark is a 2021 TEDx Talk presenter and a recipient of the WV GenerationRx Award.