Controversy over CDC guidelines on prescribing opioids for chronic pain

Guidelines created in response to the opioid epidemic in the United States have caused controversy in the medical community.
Guidelines created in response to the opioid epidemic in the United States have caused controversy in the medical community.

SAN ANTONIO—In March 2016, the Centers for Disease Control and Prevention (CDC) released guidelines on prescribing opioids for the management of chronic pain.1 These guidelines, formulated in response to the ongoing opioid epidemic that has overcome the United States, have caused much controversy within the medical community.

This controversy was highlighted by Bob Twillman, PhD, Executive Director for the American Academy of Pain Management, during his address at the academy's annual meeting.2 Dr Twillman started by expressing caution towards the numbers advanced by the CDC, regarding the opioid and chronic pain epidemics.

For example, opioid overdose-related deaths were estimated to be stable from 2009 to 2013, at about 16000, but are now estimated to have increased to 19000. These numbers are based on “information that is a little bit suspect to begin with,” noted Dr Twillman, as they are gathered from death certificates which may be filled out by medical examiners or coroners.1 In addition, heroin overdose-related deaths are included in the opioid overdose-related deaths figures.

Numbers regarding fentanyl-related deaths also include deaths resulting from illicit forms of the drug, which may have been manufactured in China and resemble a pill of hydrocodone, added Dr Twillman. “We really need to figure out how to report these numbers in a much better way,” he added.

 “We not only have 1 complex problem, but 2: prescription drug overdose and abuse and chronic pain,” he added. “The policy-makers seem to think that we can apply a simple solution, and that creates a lot of adverse and unintended consequences.”

Dr Twillman extensively emphasized the fact that these CDC guidelines are expert-based and not evidence-based. In addition, most of these experts are strongly biased, as indicated by their affiliations to, for example, anti-opioid advocacy groups.

Previous guidelines on the “role of opioids in the treatment of chronic pain” published in September 2014 by the National Institutes of Health and based on literature review were formulated by an unbiased expert panel, which concluded “What was particularly striking to the panel was the realization that there is insufficient evidence for every clinical decision that a provider needs to make regarding the use of opioids for chronic pain, leaving the provider to rely on his or her own clinical experience.”3

According to Dr Twillman, the target should be what the patient and their healthcare provider have decided between themselves as a reasonable goal to accomplish.

There are some great risks with these guidelines, according to Dr Twillman. He took the example of the report's first recommendation that states that “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”1

Although he does not disagree with that statement, Dr Twillman thought that the important question was how to assess the nature of these nonpharmacologic therapies. In addition, he noted that oftentimes these nonpharmacologic therapies are not covered by insurance, or may not be easily accessible.

The biased nature of these guidelines is an issue, concluded Dr Twillman, “because [they are] formulated by the CDC, they are going to be accepted as gospel by many people.” He added “Inevitably, these guidelines will be accepted as the standard of care in malpractice cases, and payers are going to use [them] to establish reimbursement plans.”

Many states in 2016 have already legislated some form of the CDC recommendations for acute pain treatment, for example, limiting the use of opioid from 3 to 10 days or the dose administered. Dr Twillman recommended physicians in the audience be aware of those state laws, as they will affect their practice.

References

  1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.
  2. Twillman B. From Policy to Practice: How the CDC Guidelines Play Out in Primary Care. Presented at: AAPM 2016. San Antonio, TX; September 21-25, 2016.
  3. Reuben DB, Alvanzo AA, Ashikaga T, et al. National Institutes of Health Pathways to Prevention Workshop: the role of opioids in the treatment of chronic pain. Ann Intern Med. 2015;162(4):295-300.

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