The Center for Disease Control (CDC) revised its opioid guidelines for the first time since 2016. In their 2022 review, CDC officials emphasize an individualized approach to pain management with flexibility in treatment. While specific dosage limits were not recommended, as seen in 2016, clinicians with the CDC signal that opioid prescribing should be a last resort for most patients.
In 2016 CDC personnel worked to combat the opioid epidemic through several mechanisms. Although well-intentioned, some of the recommendations provided in the 2016 guidelines were misinterpreted as strict rules prompting large numbers of prescribers to abruptly pull back on opioid medications for all patient populations, causing an interruption in prescription care for thousands of patients. The one-size fit all approach adversely impacted those with chronic and intractable pain issues, denying those patients access to clinically prescribed pain medication. Many within this specialty population who use opioid therapy do so to engage in daily tasks or aid with everyday functions. With limited access, many patients within these unique pain populations suffered significantly from varying severities of physical/mental agony and even a heightened risk of suicide.
To illustrate the impact of the agency’s guidelines, a 2018 study from the American Cancer Society found that more than a quarter of American cancer patients could not access opioid medication due to pharmacies refusing to fill their prescriptions. CDC researchers also found that absolute limits intended to prevent misuse set by insurers “have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.” After calls for reform, medical institutions such as the Mayo Clinic have expressed their belief that the regulatory “pendulum has swung too far toward restrictive” and resulted in “under prescribing opioids for some patients populations.”
At its core, the new guidelines aim to ensure opioids are used sparingly for the general population while preserving access to those patient populations who require such medications without stigma. To rectify segments of the 2016 guidelines, the CDC is throwing its support behind a clinician-based and patient-centric model stressing compassionate pathways regarding pain management. Per the new revisions, the CDC is navigating towards a system where their recommendations are utilized to guide and educate clinicians while simultaneously recognizing the need for physicians to adequately assess pain patients on a case-by-case basis.
Some fundamental clarifications to the recommendations include:
- Preference toward prescribing of immediate-release opioids rather than extended-release or long-action (ER/LA) opioids.
- Wider availability and dispensing of opioid antagonists.
- Clinicians maximizing the use of non-pharmacological and non-opioid pharmacological options when handling acute pain before considering an opioid regimen.
- Evaluation period of 1-4 weeks for clinicians when prescribing to a new patient or if making changes to dosage for existing patient.
- Unless indications of a life-threatening issue present themselves, such as potential overdose opioid therapy should NOT be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.
- Clinicians should use particular caution when prescribing opioid pain medication concurrently with benzodiazepines and consider if the benefits outweigh the risks of concurrent prescribing of opioids and other central nervous system depressants.
- Detoxification without medication for opioid use disorder is NOT recommended for treating opioid use disorder as it increases the risk of resuming drug use as well as overdose.
While the Center is providing more discretion for clinicians to appropriately meet the various needs of their patients, some guidelines do call for preferences in approach. Examples include the agency’s overall favorability for non-opioid therapies regarding most subacute and chronic pain levels and its noted favorability towards prescribing immediate-release opioids rather than extended-release or long-action (ER/LA) opioids. The federal agency also promotes a “lowest effective dosage” approach to best guarantee benefits outweigh any potential risk.
The modifications of the new guidelines are likely to benefit pain patients as a whole, providing individualized access and care with minimal barriers. Updates to the opioid guidance allow clinicians more discretion to prescribe based on their patient's specific clinical needs while ensuring that opioid medications go to only those who medically require them. It is important to recognize that CDC officials accentuate that their formal recommendations are voluntary and conducted to bolster, not supplant individualized, patient-centered care.