Pain in Vain or Flexible Prescribing? CDC's Draft Opioid Guidance

Kenneth W. Lin, MD, MPH

Hi, everyone. I'm Dr Kenny Lin. I am a family physician at Georgetown University Medical Center and I blog at Common Sense Family Doctor.

In 2016, recognizing that millions of patients were receiving long-term prescriptions for opioid medications that increased their risk for opioid use disorder and overdose, the US Centers for Disease Control and Prevention published a clinical practice guideline that was intended to discourage inappropriate prescribing and improve patient safety. The American Academy of Family Physicians (AAFP) affirmed the guideline's value but expressed concerns that the CDC's strong recommendations were "based on limited or insufficient evidence."

Although "legacy" patients (those who are already on opioid therapy for chronic noncancer pain) were not the focus of the guideline, state legislators, pharmacies, and payers often rigidly interpreted its 90 mg morphine–equivalent prescribing limit along with the advice to avoid concurrent benzodiazepine use to force patients to abruptly taper opioid doses or discontinue therapy.

In a previous Medscape commentary, I worried that these arbitrary "pill limit" policies could lead to unnecessary patient suffering. Since then, observational studies have shown that tapering long-term opioid therapy is associated with an increased risk for drug overdose, mental health crisis, and death by suicideAs one of my family physician colleagues put it, it "almost feels like you're damned if you do [prescribe chronic opioid therapy] and damned if you don't." Indeed, some primary care physicians are no longer prescribing opioids for