The US Centers for Disease Control and Prevention (CDC) is clarifying its guideline on opioid prescribing to address the findings of a multidisciplinary panel of medical experts that determined health care professionals and policymakers have been misapplying the CDC’s guideline.
The CDC’s report, “No Shortcuts to Safer Opioid Prescribing,” published in the New England Journal of Medicine, addresses several of the panel’s concerns for prescribing clinicians who treat patients with chronic pain. The panel affirmed that policies and practices used by many providers have been inconsistent with the recommendations.
In the study, “Challenges With Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report,” published in Pain Medicine, the panel assembled by the American Academy of Pain Medicine Foundation identified several challenges associated with the implementation of the CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. Challenges include inflexible application of recommended dosage ceilings and prescription durations, availability of multimodal pain care, and failure to include patient involvement in the decision to taper or discontinue opioids.
“The guideline does not support abrupt opioid tapering or discontinuation,” says Debbie Dowell, MD, MPH, chief medical officer, CDC—National Center for Injury Prevention and Control. “There have been concerns raised that some patients might turn to illicit opioids, such as heroin. We don’t yet know how commonly this occurs, but CDC is funding research to study this.”
Published in response to the increase in opioid misuse, the recommendations were intended to help identify risks associated with long-term opioid therapy, improve communication between clinicians and patients on the benefits and risks of opioid use for chronic pain, and improve the effectiveness of pain management. However, the panel determined some clinicians are treating these recommendations as hard-and-fast rules by enforcing hard limits on opioid doses, and abruptly tapering or stopping patients’ opioid prescriptions—negatively affecting patients. Clinicians are also misapplying recommendations to populations outside of the guideline’s scope, including patients in active cancer treatment.
“The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain primarily addresses chronic pain, but it also addresses nontraumatic, nonsurgical acute pain. An example of misapplication of the guideline noted in the commentary is application of the guideline to pain associated with major surgical procedures,” says Dowell.
To mitigate these challenges, the panel recommends shifting the focus to maintain pain control through alternative therapies, promote patient education on dose tapering and the risks/benefits of opioid therapy for chronic pain, and to track outcomes of interventions intended to reduce opioid prescriptions.
The CDC is evaluating the impact of the guideline on clinicians’ prescription practices and patient outcomes. Recommendations will be updated once new evidence is available.
One takeaway is that oral health professionals should consider nonopioid therapies first. Prescribing fewer pills, educating patients about the benefits and risks of prescription opioids, and considering the use of anti-inflammatory drugs (NSAIDs), alone or in combination with acetaminophen, as a first-line therapy are all recommended strategies for fighting opioid abuse.