The CDC’s New Pain Treatment Advice Aims To Correct the Damage Done by the 2016 Version
The revised and expanded pain treatment guidelines that the Centers for Disease Control and Prevention (CDC) published today mention “patient abandonment” eight times. They also include two occurrences of this admonition, in bold and italics: “Clinicians should not abandon patients.“
That gives you a sense of the disastrous impact that the original version of the CDC’s advice, published in 2016, had on medical care. Something clearly has gone terribly wrong when clinicians have to be reminded that they are not supposed to abandon patients. At the same time, the CDC’s acknowledgment of the problem signals its willingness to address the needless suffering caused by the 2016 guidelines, which resulted in undertreatment, reckless “tapering” of pain medication, denial of care, and procrustean policies that prioritize reductions in opioid prescribing over the interests of patients.
The original guidelines, which were aimed at primary care physicians and focused on “prescribing opioids for chronic pain,” included grave warnings about the dangers of exceeding 90 morphine milligram equivalents (MMEs) a day. Many physicians, pharmacists, insurers, regulators, and legislators read that threshold as a hard cap, meaning that it should never be exceeded and that chronic pain patients who were already above it should be forced to comply with this arbitrary limit.
Although the 2016 guidelines focused on chronic pain, they also touched on acute pain, because “long-term opioid use often begins with treatment of acute pain.” For acute pain, the CDC said, a prescription for “three days or less will often be sufficient,” while “more than seven days will rarely be needed.” As a result, the CDC notes in the new guidelines, “more than half of all states have passed legislation that limits initial opioid prescriptions for acute pain to a seven day supply or less,” while “many insurers, pharmacy benefit managers, and pharmacies also have enacted similar policies.”
Ostensibly, the guidelines were purely advisory. But in practice, many patients found to their dismay, they were mandatory.
“Some policies that were purportedly drawn from the 2016 CDC Guideline have, in fact, been notably inconsistent with the 2016 CDC Guideline and have gone well beyond its clinical recommendations,” the CDC says in the new guidelines, which are still in draft form pending public comment. “Such misapplication includes extension of the 2016 CDC Guideline to patient populations not covered in the 2016 CDC Guideline (e.g., cancer and palliative care), opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the Guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment…duration limits by insurers and by pharmacies, and patient dismissal and abandonment.”
What did all this “misapplication” mean in practice? The CDC notes that the Food and Drug Administration (FDA) “has advised that risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of suicide.”
The CDC is referring to the “safety announcement” that the FDA issued three years ago in response to complaints from patients and pain specialists. Notably, that FDA warning mentioned not just “thoughts of suicide” but completion of the act. When patients respond to CDC-inspired medical practices by killing themselves, it might be time to admit that the agency issued its advice without sufficiently considering the potential for unintended but foreseeable consequences.
The CDC never quite admits that in the new guidelines. But it has made several notable changes aimed at discouraging “misapplication” of its advice.
“This voluntary clinical practice guideline provides recommendations and does not require mandatory compliance,” the CDC says in its Federal Register announcement. “The clinical practice guideline is intended to be flexible so as to support, not supplant, clinical judgment and individualized, patient-centered decision-making.”
The revised guidelines, which include 12 main recommendations, address acute as well as chronic pain and offer advice for “clinicians” generally. They explicitly do not apply to “sickle cell disease-related pain management, cancer pain treatment, palliative care, and end-of-life care.” The new advice retains a bias against opioid treatment but, unlike the 2016 version, does not imply that daily doses of more than 90 MME for chronic pain are inherently suspect. The CDC emphasizes the importance of collaborating with patients, tailoring treatment, and weighing risks against benefits. It says that calculus includes not only the pros and cons of opioid treatment but also the dangers of abrupt dose reductions.
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