One-Year Anniversary of the CDC Opioid Prescribing Guideline
On the one-year anniversary of the Centers for Disease Control and Prevention’s (CDC) opioid prescribing guideline, an online survey of patients, doctors, and healthcare providers conducted by Pain News Network and the International Pain Foundation (iPain) found that the guideline has “harmed pain patients, reduced access to pain care, and failed to reduce drug abuse and overdoses.”
You’ll recall that the CDC Guideline for Prescribing Opioids for Chronic Pain provided “recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.” The emphasis is mine. The goal, as stated by the CDC’s web site, was to improve “… the way opioids are prescribed through clinical practice guidelines” and to “ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs.”
CDC Recommendations or Mandates?
The CDC meant well by drafting these recommendations. However, there has been broad recognition and adoption of the guideline as policy. This wasn’t the intention of the guideline.
On August 24, 2016, soon after the CDC had shared its guideline, then-U.S. Surgeon General Vivek H. Murthy “took historic action by sending a personal letter to more than 2.3 million health care practitioners and public health leaders.” In that letter, he asked these physicians and thought leaders to pledge to “turn the tide” of opioid addiction, and he touted the CDC guideline as a “good place to start.” In other words, his letter suggested that cutting back on the number of opioid prescriptions was a priority for ending the opioid epidemic.
Pain News Network and iPain Surveys Chronic Pain Patients
Just as the Pain News Network and iPain survey reported that patients are finding it increasingly difficult to receive the opioid prescriptions they need to manage their pain, The Centers for Medicare and Medicaid Services (CMS) took matters a step further “by mandating [the guideline] as official Medicare policy and taking punitive action against doctors and patients who don’t follow them.” Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management, commented in Pain News Network: “When CDC released its guideline, many feared that policymakers and payers would quickly move to convert CDC’s voluntary recommendations into mandatory regulations, which appears to be coming true, both with CMS and with private payers.”
The results of the survey are not surprising. According to Anson’s article, since the “voluntary” implementation of the CDC’s guideline a year ago, “…over 70 percent of pain patients say they are no longer prescribed opioid medication or are getting a lower dose. While reducing opioid prescriptions may have been the ultimate goal of the guideline, it came with a heavy price: Eight out of ten patients say their pain and quality of life are worse. Many are having suicidal thoughts, and some are hoarding opioids or turning to illegal drugs for pain relief.”
Assessment of the CDC Opioid Prescribing Guideline
The guideline has had far-reaching effects. It would seem any policy that affects as many people as the opioid prescribing guideline has should be assessed to determine the impact it’s had — especially since it is poised to become mandatory rather than voluntary. Assessment should include the number of opioid-related overdose deaths, number of ER admissions for opioid-related overdoses, and the number of people admitted for treatment of opioid use disorder since the guideline’s introduction, and how that compares with the numbers before the guideline was introduced.
Perhaps there should also be an estimate of the economic windfall to payers because of the fewer opioids prescribed to patients. After all, the payer community was involved in developing the CDC opioid prescribing guideline.
Most importantly, there should also be an assessment on the impact the guideline has had on patients’ access to adequate pain management. Unfortunately, it doesn’t appear any such assessment is planned.
Based on the results of the survey and hundreds of emails I have received; it may be appropriate for the CDC to invite the pain community to help revise the guideline to create a public heath policy that strikes a better balance of avoiding opioid-related problems while allowing opioids to be used in a responsible way. The proper use of opioids, under any public health policy, should be determined by clinicians who treat people in pain and informed by their patients’ individual needs.
Finally, any guideline that is proposed without acknowledging the needs of people in pain runs the risk of worsening the opioid problem and causing people who are in pain to suffer more than they must. It is time for the CDC to assess the impact the guideline has had for people in pain and to act on their findings.
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Copyright 2017, Lynn Webster, MD