Three years ago, when the opioid epidemic was first garnering significant national media attention, the Centers for Disease Control (CDC) released a report called CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. The report was a direct, public response to the overwhelming and inescapable fact that the opioid situation in the U.S. was beyond troubling and far past a matter of simple concern: it was a full-blown crisis.
You can read our article on those CDC Guidelines here: “CDC Opioid Guidelines: Challenges in Implementation.”
We discussed the guidelines themselves, as well as reactions to the guidelines published by the American Academy of Pain Medicine (AAPM) and the New England Journal of Medicine (NEJM). The AAPM convened a consensus panel of subject matter experts, which identified several ways in which physicians, policy makers, and healthcare providers were misinterpreting and misapplying the guidelines, and offered practical recommendations to correct these problems in order to benefit the most patients while harming the fewest.
In 2019, the CDC – possibly in response to the commentary published by these two well-respected and well-established professional organizations – released a media statement with the following title:
“CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain: Some policies, practices attributed to the Guideline are inconsistent with its recommendations”
In the media statement, the CDC clarifies its position with regards to opioid prescriptions for chronic pain. While they don’t revise the guidelines, they do directly address the problem areas pointed out by the AAPM Panel, and reiterate something they attempted to spell out plainly from the start:
“Clinical decision making should be based on a relationship between the clinician and patient, and an understanding of the patient’s clinical situation, functioning, and life context. The recommendations in the guideline are voluntary, rather than prescriptive standards.”
We’ll take a look at the new media statement in a moment. For now, we’ll update you on the latest statistic on the opioid crisis.
Opioids in 2018: New Challenges
The statistics in 2016 were disturbing, and though progress has been made in a short time, the final numbers for 2018 show we’re still a nation in the midst of a serious public health emergency.
Here’s the 2018 data:
- 47,600 people died from opioid overdose
- That’s about 130 people a day
- 3 million people misused prescription opioids
- 2 million people misused prescription opioids for the first time
- 32,656 overdosed on a synthetic opioid
- 2 million people had an opioid use disorder
- 808,000 people used heroin
- 81,000 people use heroin for the first time
- 15,349 people overdosed on heroin
Those numbers are the reason we’re still in crisis, the reason we can’t take our eye off the ball, and the reason why the CDC’s recent press statement matters. As a society, we made a great hue and cry over the opioid crisis in 2017-2018, but we have to keep focused and understand the measures we took then were neither perfect nor all we need to do. Just like a treatment plan for an individual in recovery from addiction, the treatment plan for the nation needs continuous examination, revision, and improvement – otherwise, we’ll get stuck resting on our laurels while people still need help.
The New CDC Statement: What It Says
We’ll frame this by revisiting the two primary problems that arose from the CDC guidelines, presenting the AAPM Panel recommendations to remedy the problems, then offering the CDC response to the AAPM Panel positions.
Problem 1: The inflexible application of recommended ceiling doses or prescription duration.
- The AAPM Recommendation: The panel concluded that “…any legislative regulatory, or payer policies enacted should make provisions for appropriately selected and monitored patients who need and benefit from longer duration or higher dosage.”
- The CDC Response: “Misapplication of the Guideline’s dosage recommendation that results in hard limits or cutting off opioids. The Guideline states, “When opioids are started, clinicians should prescribe the lowest effective dosage.” The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.”
Problem 2: Abrupt opioid taper or cessation in physically dependent patients without empathetically reviewing benefits and risks in collaboration with patients.
- The AAPM Recommendation: The panel concluded that “abrupt cessation of opioids is medically risky and outside the intent of the CDC guideline.” They emphasized “gradual and supported taper with patient engagement and cautioned that clinicians should not…automatically and immediately reduce or stop long-term opioid therapy or dismiss patients with risk factors from care.”
- The CDC Response: “The Guideline does not support abrupt tapering or sudden discontinuation of opioids. These practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids. In addition, policies that mandate hard limits conflict with the Guideline’s emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient.”
Addressing Misapplications of the Guideline
In addition to the two primary problems that arose during the public (read legislative) and private (read physicians and insurers) application of the guidelines, there were also problems with the guidelines being applied to populations outside their scope.
In some cases, the applications were applied to the following groups of people:
- Patients in active cancer treatment
- Patients in acute sickle cell crisis
- Patients experiencing post-operative pain
- Patients receiving or initiating medication-assisted treatment (MAT) for opioid use disorder.
In all the cases above, the CDC press statement re-emphasizes that the guidelines were meant for patients using opioids for managing chronic pain – full stop. With regards to patients on long-term, high-dose opioids, the CDC statement reminds all relevant parties that the guidelines include specific advice for providers to:
- Explore and maximize non-opioid treatment options
- Review risks associated with high-dose opioids empathetically
- Work with patients who consent to tapering their opioid dose
- Taper in a safe, sane manner that minimizes the discomfort of withdrawal symptoms
- Tailor each taper to the specific needs and circumstances of each patient
- Monitor and mitigate risk of overdose for high-dose patients
Finally, as an addendum to the opioid guidelines, the CDC produced the following resources to further help physicians, legislators, and providers assistance in the safe and effective application of their prescription guidelines:
A Pocket Guide for Tapering Opioids: This pdf is designed for physicians considering tapering their patients off long-term opioid use.
CDC Opioid Guideline Mobile App: This app is also designed for physicians or other providers in order to help them apply the CDC guidelines appropriately. The app includes the Morphine Milligram Equivalent Calculator (MME), guideline summaries, and recommendations about productive ways to communicate critical information about opioids to patients.
The CDC Prescribing Opioids Series: This is an 11-part, interactive, web-based training series designed to help providers fully understand how to apply the CDC guidelines.
Comprehensive, Collaborative Solutions
It’s important to remember that the opioid crisis didn’t happen overnight. It happened over the course of at least a decade, and coincided with the development of new, more powerful opioid drugs, a dramatic increase in opioid prescription rates, and the mistaken belief that the new class of opioid drugs – including Oxycontin and Fentanyl – were not addictive in the same way that previous generations of opioid drugs were.
With that said, how we arrived here – at least from our point of view as addiction treatment providers – is immaterial.
What matters is how we react and what we do next. The CDC Guidelines, when published in 2016, were a welcome, necessary, and helpful event in the ongoing effort to save lives and heal people from the pain of opioid addiction. They were never meant to be used dogmatically, word-for-word, as a template for best practices for prescribing opioids or the long-term management of chronic pain – but in many cases, they were.
The response from the American Academy of Pain Medicine (AAPM) and the New England Journal of Medicine (NEJM) was crafted to bring awareness to the fact that the CDC guidelines were being misinterpreted, often causing additional pain and suffering for patients.
Their effort worked.
The CDC listened and responded themselves, offering additional clarification and a set of guidelines for their guidelines – which is somewhat ironic, but in this case, completely necessary. Their new resources – the pdf, the app, and the web training series – all foreground a principle they emphasized in their original publication, which many medical professionals seemed to miss: any clinical decision should be based on an open and honest relationship between doctor and patient, and should always include a compassionate and empathetic understanding of the patient’s specific biological, physiological, emotional, and social needs.
That’s how we’ll survive the opioid crisis: listening to one another, working together, and finding a practical, healthy path forward that’s both fact-based and patient-centered.