By Andrew Joseph Feb. 10, 2022
ADOBE
Federal health officials on Thursday abandoned their influential recommendations that opioid prescribers should aim for certain dose thresholds when treating chronic pain.
The changes came as part of a proposed update to the Centers for Disease Control and Prevention’s controversial 2016 guidelines on opioid prescribing. The recommendations are an attempt from health officials to strike a balance between limiting the harms that can come from long-term opioid use; allowing for physicians to come up with individualized plans to treat their patients; and encouraging reductions in dosages when it can be done safely and with patient buy-in.
The newer guidelines still say that “opioids should not be considered first-line or routine therapy for subacute or chronic pain” and note that other treatments are often better for acute pain as well. Doctors should prioritize non-opioid medications and interventions like exercise and physical therapy, according to the recommendations.
Gone, however, is language that says doctors should “avoid increasing dosage” to 90 morphine milligram equivalents or more per day or to “carefully justify” such a decision. The CDC guidelines were always meant to be voluntary, but policymakers sometimes interpreted the 90 MME figure as a hard ceiling for what doctors could prescribe — even though many chronic pain patients were already on higher dosages.
Instead, the newer recommendations say that “clinicians should prescribe the lowest dosage to achieve expected effects.”
Similarly, the updated guidelines no longer indicate time limits for prescriptions for acute pain. The 2016 version suggested “three days or less will often be sufficient; more than seven days will rarely be needed.”
The CDC is accepting comments on the draft through April 11. A finalized update is expected this year.
The guidelines also offer recommendations for “whether, when, and how to taper opioids” — meaning how to safely lower patients’ doses. The CDC urges doctors to find the lowest possible dose that can still reduce their patients’ pain.
In many ways, the proposed changes to the guidelines are a victory for experts and patient advocates who have argued for years that despite the CDC’s intentions, the guidelines were resulting in physicians unsafely tapering patients or cutting patients off entirely — in part because of the specific dosage benchmarks included in the guidelines.
The 2016 guidelines became a major flashpoint in the ongoing — and often contentious — debate over how tightly to limit the opioid prescribing patterns that helped ignite the country’s overdose crisis, and the unintended harms being imposed by those efforts. Experts disagree over whether opioids should be used as a chronic pain treatment broadly at all. Doctors who encourage patients to try to lower their doses point to various harms from long-term, high-dose opioids — not just the risk of addiction and overdose, but possible mental health consequences and perhaps even worse pain sensitivity.
Opioid prescriptions have been falling since 2012, as the medical community realized it needed to reassert control over how laxly the medications had been prescribed. The declines accelerated after the publication of the 2016 guidelines.
The authors of the original guidelines have stressed that they were just recommendations for certain patients in certain settings, but they were sometimes cited by states and insurers to impose hard caps on the duration and dosages of opioid prescriptions. More broadly, the fear of attracting scrutiny from authorities for prescribing high-dose or long-term opioids led many doctors to stop treating these patients or to rapidly reduce their dosages.
As a result, advocates and some experts argue, patients could no longer get necessary treatment for their chronic pain. Moreover, some patients who had been on the pills for years and whose dosages were unsafely slashed sought out illicit supplies of opioids; some even took their own lives.
The authors of the original guidelines wrote in the New England Journal of Medicine in 2019 that their recommendations had been misapplied and were wrongly being used to cut off patients or to justify unsafe tapers.
It’s a message they reiterated throughout the updated proposal, saying, for example, that while tapering or discontinuing opioids could be a goal for some patients when the risks of continuing use outweighed the benefits, “clinicians should not abruptly or rapidly reduce opioid dosages from higher dosages” except in emergencies.
Like the 2016 version, the new guidelines are not meant to apply to patients with cancer or sickle cell disease, nor do they apply to end-of-life pain care.
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