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The Centers for Disease Control and Prevention have published new direction for clinicians on how and when to prescribe opioids for pain. Released on Thursday, it revamps the agency’s 2016 recommendations that some doctors and patients have criticized for promoting a culture of austerity around opioids.
CDC officials say doctors, insurers, pharmacies and regulators sometimes misapplied old guidelines, causing some patients significant harm, including “untreated and undertreated pain, severe withdrawal symptoms, worsening pain outcomes, psychological distress, overdose and [suicide]”, according to the updated guidelines.
The 100-page document and its key recommendation serve as a roadmap for prescribers navigating the thorny issue of pain treatment, including advice on managing pain relief after surgery and managing pain conditions. chronic, which are estimated to affect up to one in every five people in the United States
The 2016 guidelines have proven hugely influential in shaping policy – fueling a push by insurers, state medical boards, politicians and federal law enforcement to curb opioid prescribing.
The fallout, doctors and researchers say, is hard to overestimate: an untreated pain crisis. Many patients with severe chronic pain have had their long-standing prescriptions quickly reduced or removed altogether, sometimes with disastrous consequences, such as suicide or overdose, as they turn to the tainted supply of illicit drugs.
Federal agencies had tried to correct the situation, clarifying that the old voluntary guidelines were not intended to become hard policies or laws. But doctors and patient advocates also remained hopeful that the CDC’s updated guidelines would undo some of the unintended consequences of the earlier guidelines.
That was clearly on CDC health officials’ minds when they announced the new clinical guidelines on Thursday.
“The recommendations in the guidelines are voluntary and intended to guide shared decision-making between a clinician and a patient,” said Christopher Jones, acting head of the CDC’s National Center for Injury Prevention and Control and co-author of the guidelines. updates, during a press conference. briefing, “It is not intended to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, government entities.”
The shift in perspective is evident throughout the new guidelines, says Dr. Samer Narouzepresident of the American Society of Regional Anesthesia and Pain Medicine.
“You can say the culture around the 2016 guidelines was right to cut opioids, that opioids are bad,” he says. “It’s the opposite here, you can feel they care more about patients who are living in pain. It’s more geared towards relieving their pain and suffering.”
A New Emphasis on Individualized Care
The prescription of opioids began to decline in 2012 and this trend continued after the publication of the 2016 guidelines. There is broad consensus that opioids should be used with caution due to the risks associated with addiction and overdose. But today the majority of overdose deaths are not due to prescription opioids, but rather to fentanyl and other illicit drugs.
Addressing the illicit drugs driving today’s overdose crisis is “not the purpose of this directive,” Jones said, describing the efforts as a separate but parallel “whole of government” approach. Instead, the focus is on patients with pain. “The goal is to advance pain, function and quality of life [for patients] while reducing the abuse, diversion and consequences of prescription opioid abuse,” Jones said.
The new guidelines still emphasize that opioids should not be the treatment of choice in many cases, emphasizing that other treatments and approaches are often comparable in improving pain and function. However, the guidelines make it clear that counseling should not replace clinical judgment and that clinicians can work with patients who are in pain, even if it means continuing to take opioids.
“Each patient is a different story and deserves individualized care,” says Narouze. “That’s what I like the most about the new guidelines.”
More work to do
While the voluntary guidelines are a welcome step, their impact largely depends on how state and federal agencies and other authorities respond to them, says Leo Beletskyprofessor of law and health sciences at Northeastern University and director of the Health in Justice Action Lab the.
“The CDC needs to be much more proactive than just releasing this update and trying to reverse some of the misinterpretations of the previous version,” he says. The agency must work with other federal agencies, he says, including health and human services and the Drug Enforcement Administration, as well as law enforcement to implement these guidelines.
For example, Beletsky points out how the definition of high-dose opioid use – described as 90 or more milligram equivalents of morphine Daily in the 2016 recommendations – was used to establish legal limits. “The  the guideline itself was clear that it was not a clear line rule,” he says, “but it became a de facto label, separating appropriate and inappropriate prescribing,” he says. he. And it has led law enforcement in some states to use the limit “as a sword to prosecute prescribers.
These doses and limits — set without much scientific evidence to back them up — have had a chilling effect on doctors, says Cindy Steinberga patient advocate with the US Pain Foundation.
“Most people I know – and I know a lot of people with chronic pain – have already stopped taking their medication. Doctors are incredibly scared to prescribe.” From Steinberg’s perspective, the new CDC guidelines remain too restrictive and won’t make much of a difference for patients who have already been harmed.
Specific dose and duration limits are exceeded
The most significant changes in the new guidelines come in the form of 12 bullet points that set out general principles related to prescribing.
Unlike the 2016 version, these takeaways no longer include specific limits on the dose and duration of an opioid prescription a patient can take, although deeper in the document it warns against prescription above a certain threshold. The new recommendations also explicitly warn doctors against rapidly reducing or stopping prescriptions for patients who are already taking opioids – unless there are indications of a life-threatening problem.
“I think they’re very understanding and compassionate,” says dr. Antje Barreveld, Medical Director of Pain Management Services at Newton Wellesley Hospital. “These arbitrary markings of what is acceptable and not acceptable are what got us into trouble with the 2016 guidelines because it cut that coverage off for our patients and it’s not about pain management. “
The guideline on reducing opioids when possible still raises some concerns for clinicians like Stefan Kerteszprofessor of medicine at the University of Alabama at Birmingham.
“I would point out that when you take a stable patient and reduce [their prescription], you are engaged in an experiment,” says Kertesz. “Dose reduction is simply an uncertain intervention that sometimes helps and sometimes kills the patient. So I would have preferred them to say, “Look, it’s an uncertain intervention.”
However, he adds that the strength of the new guidelines lies in the repeated insistence that a specific dose should not be used by agencies, law enforcement and payers to apply a one-size-fits-all approach.
Unraveling rigid opioid prescribing policies
It is uncertain whether the new guidelines will result in substantial changes for patients struggling to get their pain treated.
Many patients currently cannot find treatment, following 2016 guidelines, Barreveld says, because doctors are hesitant to prescribe at all.
She recalls a recent case where one of her elderly patients suffered from severe arthritis in her neck and knees. “I recommended to the primary care physician to start low-dose opioids and the primary care physician said ‘no,'” Barreveld said. “What happened? The patient was admitted to the hospital, thousands of dollars a day for eight days, and what did she come out on? Two to three opioid pills a day.”
The previous guidelines led to the limitations on limitation being codified as policy or law. It is not clear that these rules will be rewritten in light of the new guidelines, although they state that they “are not intended to be implemented as absolute limits on policies or practices”.
“It’s a good idea, and it will have absolutely no effect unless three major agencies act immediately,” Kertesz says. “The DEA, National Committee for Quality Assurance, and Centers for Medicare and Medicaid Services, the three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality measurements and forensic investigations.”
The ability to coordinate and repair the damage resulting from the 2016 guidelines rests with the leadership of the CDC — an agency whose credibility and authority have been damaged during the COVID-19 pandemic, Beletsky says. Still, the agency has learned criticism and harm from the latest round of advice. “So hopefully the CDC is now better equipped and prepared to take the directive and translate it to the ground level,” he says.
The quality of life of many chronic pain patients will depend on it.