The Centers for Disease Control and Prevention (CDC) recently issued revised guidelines to help safely prescribe opioids, and one of the reasons, the agency freely admits, is to clear up confusion caused by its last set of guidelines issued in 2016.
Most importantly, the new document emphasizes that its recommendations are just that – recommendations and not iron-clad rules, says Fredericksburg pain specialist Ralph Menard, MD, president of the Texas Pain Society (TPS). It also eliminates mention of specific dosages that could be misinterpreted and stresses that while opioid use by patients should be minimized, it is sometimes needed.
The new guidance comes at a time when opioid prescriptions are dropping but overdose deaths from illegal opioids are skyrocketing.
CDC’s previous guidance from 2016 contained helpful suggestions, but many people – lawmakers, insurance companies, pharmacies, physicians, and other health care professionals – misinterpreted or misused those guidelines, CDC says.
As a result, opioid prescriptions became difficult or impossible to obtain for many pain patients, even for those with long-standing problems who had been stable on their medications, says Mesquite pain management specialist C.M. Schade, MD.
“There was a huge influx of patients [to my office] from primary care, from everywhere, because they couldn’t get any pain medicine,” he said.
The 95-page 2022 guidelines appear to be a big improvement over the 2016 version because they acknowledge past errors and don’t repeat those mistakes, Dr. Menard says.
Physicians and other decision-makers in the health care industry now need to make sure they interpret these new guidelines correctly this time around, he adds.
Guidelines vs. rules
One of the biggest problems with the 2016 guidelines is that many in the medical community did not treat them as guidelines, Dr. Schade says. Since they came from CDC, they were wrongly treated as inflexible rules that applied to all physicians in all cases.
For instance, the 2016 guidelines gave recommendations about the “morphine milligram equivalent,” or strength of the medication, that is acceptable for primary care physicians to prescribe, but not intended for subspecialists like pain physicians or oncologists who regularly treat pain, says San Antonio anesthesiologist and pain mediation expert Maxim Eckmann, MD, immediate past president of TPS. “The guidelines became broadly interpreted as sort of reflective of the standard of care for all physicians treating pain and with relative inflexibility,” he said. “So certain states and stakeholders in states and medical boards started to enforce those limits, and payers did too. The Medicaid program and others enforced these limits as if they were a hard stop, and they were never really meant to be that way.”
Many states – including Texas – enacted laws limiting initial opioid prescriptions to 10 days or less. Also, insurers, pharmacy benefit managers, and pharmacies created similar policies.
Although these laws, regulations, and policies might have helped keep some people from overusing opioids, “they are inconsistent with a central tenet of the guideline: that the recommendations are voluntary and intended to be flexible to support, not supplant, individualized, patient-centered care,” CDC said.
That misapplication and inflexibility has, among other problems, forced patients to greatly cut back on or lose access to opioid-based medicines when they needed them, according to CDC.
CDC‘s new guidance emphasizes that the agency is strictly making recommendations and those recommendations do not include any specific dosages that could be mistakenly used to create rules about how much a physician can prescribe, Dr. Menard says.
“They don’t mention limits on anything,” he said.
Preventing desperation
Some patients were able to lower the dosage of their opioid medications or stop taking them with no problems, but “there are reports of people committing suicide, or they went to illicit sources for pain medication,” Dr. Menard said.
While opioid prescriptions nationwide have dropped 46% between 2012 and 2021, “drug-related overdose and death continue to increase, primarily due to illicitly manufactured fentanyl and fentanyl analogs,” according to the American Medical Association’s 2022 Overdose Epidemic Report.
The number of overdose deaths involving synthetic opioids in 2020 was more than 18 times the number in 2013, accounting for more than 56,000 overdose deaths in 2020, according to CDC.
The backlash against the opioid epidemic still makes it hard for patients who need pain medication to get it in many cases, Dr. Menard says. “The problem is still based on those guidelines from 2016,” he said. “Many of those primary care doctors are still not prescribing any pain medication,” which can prolong patients’ pain and kick a treatable condition to other physicians.
Education, he says, and hopefully the new guidelines, will be key to addressing treatable pain conditions.