12/2/2022
The Centers for Disease Control and Prevention (CDC) has released a newly updated set of guidelines for clinicians prescribing opioid painkillers, removing some hard limits on medication doses and duration of treatment.1
The agency released its new set of recommendations after a public comment period in which patient advocacy groups pushed to soften some of the CDC’s previous recommendations and give stronger consideration to those who live with chronic pain.
The new guidelines replace the CDC’s 2016 guidelines for prescribing opioids, whose strict caps on medication dosage and duration led to a crisis of inadequate care for chronic pain patients, including forced tapering or abrupt discontinuation of opioid medications, denial of care at some medical practices, and untreated physical and psychological side effects.2
Whereas the 2016 guidelines led to overly broad, rigid policies that discouraged clinicians from prescribing opioids, the new guidelines promote individualized care and allow doctors more flexibility to use their best judgment.3
Doctors are still urged in the 2022 guidelines to use nonopioid treatments whenever possible, including NSAIDs and alternative pain management techniques such as physical therapy. And the new guidelines encourage clinicians to start opioid treatment with the lowest effective dose, and to prescribe immediate-release rather than long-acting forms of medications.
SAA spoke to Kate Nicholson, JD, founder and executive director of the National Pain Advocacy Center (NPAC), to discuss what the new opioid guidelines mean for those who live with chronic pain.
What is the significance of the 2022 CDC guideline for people who live with chronic pain?
KN: This CDC Guideline, unlike the 2016 one, emphasizes flexibility in treating pain, underscores the importance of individualized, patient-centered care, and returns discretion to providers. It also removes thresholds related to opioid dosing and the number of days opioids should be prescribed from its main recommendations.
Regulators had adopted these thresholds as one-size-fits-all laws and mandates, causing harm to people with pain.
These harms include the medical abandonment of patients who use opioids and dangerous opioid cessation practices that studies show actually increase the risk of overdose and suicide by three to five times.
Our hope is that this new framework and approach of flexibility will allow patients and providers to make the right decisions for health and care.
Does the new update do what NPAC hoped it would?
KN: No. We still have significant concerns with this document. For one, although it removed the dose thresholds from the main recommendations, these thresholds (while qualified) remain in the text. It’s easy for regulators to strictly apply numbers. Presentations at the FDA have questioned the application of such thresholds, expressed as MMEs (or morphine milligram equivalents) in any one-sized way to patients.
In addition, the guideline still labels non-opioids as “preferred treatment,” which is both payer [health insurance company] language and a statement of value. Although we agree that opioids are not typically a first line of treatment, we are concerned that the CDC’s use of payer language to prefer options that are not well-compensated by payers will increase equity [access] issues.
Finally, the new update is greatly expanded to cover the full spectrum of pain: acute, subacute and chronic. The 2016 Guideline covered only chronic pain. This is fine in theory. But well-acknowledged harms emerged from the 2016 guideline causing risks to patient safety—that the CDC itself acknowledges. Usually you check to make sure your safety system works before you expand the fleet.
What short-term or long-term trickle-down effects might chronic pain patients expect to see? (Or what do we hope they will see?)
KN: We are hopeful that providers will feel freer to exercise their best medical judgment and that patients will no longer be abandoned in care. But protecting patients will require regulators who applied the CDC’s original guideline strictly to correct course.
What comes next in the effort to improve treatment and quality of life for this population?
KN: Working with regulators to rescind harmful policies and expanding coverage of a variety of pain treatments.
Our thanks to Kate Nicholson, JD, for sharing these insights. If you would like to share thoughts, questions, or concerns about the new CDC guidelines, or share your experience with accessing opioid medications, please reach out to SAA at programs@spondylitis.org.
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