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 suicide. As 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 inherited patients with chronic pain and instead are referring them to pain management clinics that have months-long waitlists.

In this context, the CDC recently released a draft update of its 2016 guideline. Of note, the update includes several pointed statements that its recommendations should not be construed as inflexible standards to deny therapy or excuses for clinicians to abandon patients who are taking higher opioid doses. It also expands the scope of the previous guideline to encompass opioids for acute pain and includes a suggested approach to patients who are already taking chronic opioid therapy. These changes should hopefully protect patients from involuntary opioid discontinuation and improve the guideline's clinical usefulness.

On the negative side, the guideline is painfully long compared with the previous version. The authors seem to feel that it's necessary to reiterate every study finding and expert comment that supports one or more recommendation, even though the supporting systematic reviews of treatments for acute pain and chronic pain are freely available on Agency for Healthcare Research and Quality's website.

Despite the exhaustiveness of the literature searches, this guideline, like its predecessor, makes sweeping recommendations on the basis of limited or insufficient evidence: Only one out of the 12 recommendations is supported by high-quality evidence whereas seven recommendations are based primarily on expert opinion.

Finally, I searched the guideline in vain for an acknowledgement that the majority of drug overdoses are now related to illicitly manufactured opioids, particularly fentanyl. That doesn't mean we should not be prudent about prescribing opioids for acute and chronic pain, but it is important to put physicians' contributions to this problem into perspective.

Primary care physicians are ideally suited to manage chronic pain because of our longitudinal relationships with patients and ability to provide comprehensive care for their physical and mental health concerns. The draft CDC update takes some positive steps toward restoring physician autonomy for prescribing opioids and supporting shared decision-making in patients who are at increased risk for opioid-related harms.

This update is not a one-stop shop resource for chronic pain management; nonopioid therapies are mentioned but not discussed in great detail. For more information on nonopioid and nonpharmacologic treatments, I recommend consulting the AAFP's Chronic Pain Management Toolkit and American Family Physician's collection of articles on chronic pain conditions.

The draft recommendations remain open for public comment via the Federal Register's website through April 11, 2022.

Kenny Lin, MD, MPH, teaches family medicine, preventive medicine, and health policy at Georgetown University School of Medicine. He is deputy editor of the journal American Family Physician.

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Cite this: Kenneth W. Lin. Pain in Vain or Flexible Prescribing? CDC's Draft Opioid Guidance - Medscape - Mar 22, 2022.