CDC Expands Opioid Guidance to Include Acute Pain and Additional Providers

The Centers for Disease Control and Prevention (CDC) has released its Clinical Practice Guideline for Prescribing Opioids for Pain (2022). Updated and revised, this new guidance is intended to replace the CDC’s 2016 opioid guideline. While the previous guideline was limited in scope to primary care providers treating chronic pain in adults, the new guidance has been broadened to provide evidence-based recommendations for prescribing opioid pain medication for acute, subacute, and chronic pain for outpatients aged ≥18 years, excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care. Further, and of vital importance, the CDC has made it explicitly clear that its guideline is intended to be voluntary and not to be used as an inflexible standard of care by health systems, insurers, or legislatures.

The 2022 Clinical Practice Guideline addresses the following areas:

1. Determining whether to initiate opioids for pain,
2. Selecting opioids and determining opioid dosages,
3. Deciding duration of initial opioid prescription and conducting follow-up, and
4. Assessing risk and addressing potential harms of opioid use.

In April of 2022, AACIPM issued a public comment to CDC regarding the guideline on behalf of 44 individual and organizational signatories representing a broad spectrum of health care providers, payors, academia, policy and healthcare experts, and people living with pain. The group expressed support for a number of aspects of the proposed guideline, made a number of suggestions for improving the guideline, and outlined a number of ways that CDC could ensure a robust and effective dissemination effort related to the release of the updated guideline.

Ultimately, all three points that AACIPM supported in CDC’s proposed guideline made it into the final guideline, including:

• Removal of Dosage Thresholds (aka “Ceilings”) and Stronger Emphasis on Patient-Centered Care
• Emphasis on Non-Opioid, Non-Pharmacological, and Integrative Therapies and Acknowledgment that Reimbursement is a Significant Barrier
• Explicit Intention that the 2022 Guideline is Voluntary and Not an Inflexible Standard of Care

AACIPM had also advocated that three changes be made to the guideline. While our concern regarding the use of the term “preferred” went unheeded, as did our recommendation to include a visual pain management toolbox, we were successful in securing amendments related to acute pain. AACIPM had stated our concern with the lack of statement related to acute pain that clinicians should discuss treatment goals and eventual discontinuation of opioids with a patient “before starting opioid therapy”, as was recommended in the treatment of chronic pain. The lack of such a statement related to acute pain would have been problematic, because (1) opioid therapy is often initiated during the acute phase, not the subacute/chronic phase, with transition to a new phase being gradual, and (2) it would have implied that no discussion of treatment goals and eventual discontinuation is required if prescribing for acute pain. CDC did ultimately make this change, adding the following statement to Recommendation 1: Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

AACIPM stakeholders have offered a number of thoughts on the revised guidelines, from various perspectives:

American Medical Association (AMA) urges all stakeholders to follow the CDC and replace all current policies based on the old guideline to align with the 2022 guideline recommendations. Failure to do so will result in continued misapplication and harm to patients with pain and physicians who treat patients with pain. Further, AMA strongly supports CDC’s emphasis on shared decision-making and the importance of not using the guideline as justification for discontinuing patient care or stigmatizing patients with pain. However, AMA also points out that the 2022 guideline also contains a strong preference for non-opioid and non-pharmacological therapies but does not meaningfully explain how or why payers would increase access to these therapies. Read more.

U.S. Pain Foundation believes that the CDC’s updated guideline has small improvements over the original 2016 Guideline, but that it does not go nearly far enough in correcting the serious problems that arose from the 2016 Guideline. The organization is concerned with the guideline from a scientific perspective, as 10 of the 12 recommendations are based on “very weak” or “weak” evidence. Further, while the guideline has removed MME thresholds from its top line recommendations, it repeatedly makes reference to cautions and warnings regarding increasing dosages above 50 milligrams morphine equivalence (MME) through much of the supporting narrative in the Guideline–dosage cautions and limits which are, according to the organization, arbitrary and unscientific, and which have caused widespread harm, including prosecution of doctors who prescribe above those amounts and forced tapering of patients who are receiving dosages above this arbitrary amount. Read more.

Some palliative care experts in the field remain dismayed by the CDC’s process (see a recent post from PalliMed cataloguing process and content issues, particularly regarding undisclosed COIs).

Some other generalized feedback includes concerns about the extent CDC will be monitoring the adoption and implementation of the new guidelines – to help correct the problems caused when policymakers blindly adopted portions of the 2016 guideline as state legislation and regulation. Additionally, while CDC’s guidance does not specifically apply to sickle cell disease, cancer-related pain, palliative care, and end-of-life care, it is still important to recognize that using non-pharmacological approaches as a first-line approach may still be advisable, even though they are exempted from CDC’s opioid guidance.