New instructions on how and when to administer opioids for pain have been released by the Centers for Disease Control and Prevention for clinicians. This updated version of the agency’s 2016 guidelines, which were released on Thursday, have drawn criticism from some doctors and patients for encouraging an opioids-related culture of austerity.
According to the updated guidlines, CDC officials claim that doctors, insurers, pharmacies, and regulators occasionally misapplied the older guidelines, resulting in serious harm to some patients, including “untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and [suicide].”
The 100-page guide and its key recommendation serve as a road map for prescribers navigating the complex topic of treating pain. It offers guidance on how to handle post-operative pain relief and manage chronic pain disorders, which are thought to affect up to one in five Americans. As per NPR News, the 2016 guidelines had a significant impact on policymaking and fueled efforts to reduce opioid prescribing by insurers, state medical boards, politicians, and federal law enforcement.
It’s difficult to emphasize the consequences, according to doctors and researchers: a crisis of untreated agony. Many patients with severe chronic pain had their long-term prescriptions abruptly lowered or stopped altogether, often leading to tragic outcomes like overdosing or committing suicide as they turned to the contaminated supply of illicit medicines.
Federal authorities had made an effort to reverse their course by emphasizing that the earlier voluntary guidelines were never meant to be binding regulations or laws. Doctors and patient activists, however, also had hopes that the CDC’s revised recommendations would reverse some of the unintended effects of the earlier advice. When the CDC health officials released the new clinical guidelines on Thursday, they were definitely thinking about this.
According to Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control and a co-author of the updated guidelines, “The guideline recommendations are voluntary and meant to guide shared decision-making between a clinician and patient. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies, or governmental entities.”
According to Dr. Samer Narouze, president of the American Society of Regional Anesthesia and Pain Medicine, the new rules clearly reflect the change in attitude. He claims that it is clear from the 2016 recommendations’ culture that opioid use should be reduced because they are harmful. “Contrarily, you can tell that they care more about those who are in pain in this place. It’s primarily intended to alleviate their suffering and anguish.”
Following the publication of the 2016 recommendations, the prescribing of opioids continued to drop, which had begun in 2012. There is general consensus that opioids should be used with caution due to the hazards of addiction and overdose. But today, fentanyl and other illegal substances account for the majority of overdose deaths rather than prescribed opioids.
The fight against the illicit drugs that are responsible for the current overdose catastrophe is “not the purpose of this guideline,” according to Jones, who referred to those efforts as a separate but parallel “whole of government” strategy. Instead, pain patients are the main focus. The objective, according to Jones, is to improve patients’ pain, function, and quality of life while also lowering overuse, diversion, and the negative effects of prescription opioid misuse.
The updated recommendations continue to stress that opioids shouldn’t always be used as the first line of defense against pain and dysfunction, citing data to support this claim. However, it is made clear in the recommendations that the advice should not take the place of professional judgment and that clinicians can still help patients who are experiencing pain, even if that means keeping them on opioids.
Every patient has a unique tale and should receive specialized care, according to Narouze. This is the aspect of the new rules that I enjoy the most. Although the voluntary guidelines are a positive step, Leo Beletsky, professor of law and health sciences at Northeastern University and director of the university’s Health in Justice Action Lab, says that the impact of the guidelines will largely depend on how state and federal agencies and other authorities react to them.
“CDC needs to be a lot more aggressive,” he asserts, “than merely releasing this update and attempting to undo some of the misunderstandings of the previous edition.” He claims that in order to put these regulations into effect, the organization needs to collaborate with law enforcement, other government agencies, such as the Department of Health and Human Services and the Drug Enforcement Administration.
For instance, Beletsky cites how the 2016 recommendations’ definition of high-dose opioid use, which is defined as consuming 90 or more morphine milligram equivalents per day, was utilized to set legal restrictions. The  guideline explicitly stated that this was not a black-and-white rule, but it ended up serving as a de facto distinction between suitable and incorrect prescription, according to him. And as a result, some states’ law enforcement has used the limit “as a sword to go after prescribers.”
According to Cindy Steinberg, a patient advocate with the U.S. Pain Foundation, these doses and limits—set without much scientific evidence to support them—have had a chilling impact on physicians.
According to Steinberg, the updated CDC recommendations are still unduly rigorous and won’t significantly improve the situation for the individuals who have already suffered injury. “The majority of the folks I know—and I know lots of people who deal with chronic pain—have already stopped taking their medications. Doctors are quite hesitant to write any prescriptions.”
It’s unclear whether the new recommendations will result in significant improvements for patients who are having trouble getting their pain managed. According to Barreveld, many people are currently unable to access treatment as a result of the 2016 guidelines since medical professionals are reluctant to write any prescriptions.
She recalls a recent incident in which a senior patient of hers had significant arthritis in her neck and knees. I advised the primary care physician to begin prescribing low-dose opioids, but the primary care physician refused, claims Barreveld. “What took place? What was the patient’s discharge medication after being admitted to the hospital for eight days at a cost of thousands of dollars per day? Two to three opioid medications per day.”
The above recommendations caused limitations on prescribing to be enacted as policy or legislation. Despite the fact that they declare they are “not intended to be adopted as absolute restrictions for policy or practice,” it is unclear whether those rules will be revised in light of the new recommendations.
According to Kertesz, “That is a nice proposal, but it will have no impact at all unless three significant agencies act right away.” The dose thresholds from the 2016 guideline are used as the foundation for payment quality measures and legal investigation by the DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, among other authorities.
The CDC, an organization whose reputation and authority have suffered because of the COVID-19 epidemic, will need to take the lead in order to coordinate and address the problems caused by the 2016 guidelines, according to Beletsky. Nevertheless, the agency has taken note of the drawbacks and critiques of the most recent set of recommendations. Therefore, he expresses his expectation that the CDC will be better prepared to translate the guidelines to the real world.