Author: Kerry Nenn

A lot has changed when it comes to prescription opioids and how they’re prescribed.

It’s been six years. Six years since the CDC released its Guideline for Prescribing Opioids for Chronic Pain. So, why did the CDC decide to propose an update this year? What compelled the organization to take action now?

Let’s take a trip back to 2016 to find out.

Headed Toward Disaster

Over the course of two decades, use of prescription opioids in the U.S. drastically increased. The result? A full-blown opioid epidemic.

Thousands of people became addicted to painkillers. And when they grew desperate to feed their addiction, many of them progressed from prescription painkillers to illicit drugs like heroin.

Realizing the dangers, healthcare providers began to cut back on opioid prescriptions by 2012. But the damage was already done.

Opioid addiction and opioid overdose numbers skyrocketed. And what’s worse, the numbers kept climbing.

In 2016, the officials finally decided something had to change. The CDC stepped in with official prescribing guidelines, which later became known as the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. These guidelines were designed to reduce dependence on opioids and lower the risk of overdose.

After releasing the CDC guidelines, opioid laws began to change. Many states limited opioid prescriptions for acute pain to no more than seven days. Some states also limited prescriptions for Medicaid patients.

Insurance companies and pharmacies also set their own limits. Doctors began to taper long-term patients off opioids. Medical boards sanctioned doctors who didn’t adhere to the guidelines. Opioid prescriptions decreased.

Were all these actions helpful? That depends on who you ask.

Prescription Opioids: Too Strict or Too Misunderstood?

Some doctors, patients, and drug manufacturers were upset by the guidelines. They said chronic pain patients were being denied relief.

They were also concerned that doctors might be cutting patients off opioid pain relievers too quickly or failing to give prescription opioids to patients who could benefit from them.

Dr. Bobby Makkumala, head and neck surgeon in Michigan, said the guidelines

“…have been a barrier to patient care, with some pharmacists pointing to the CDC’s suggested limits and refusing to fill prescriptions as doctors wrote them.”

Keith Humphreys, Stanford University psychiatry and behavioral sciences professor, noted:

“It’s important to tailor policies to a patient’s individual circumstances rather than adopt a blanket approach for all.”

One survey found that 84 percent of patients reported having more pain and poorer quality of life after the opioid prescribing guidelines were released.

But others didn’t see a problem with the overall guidelines – just with how they were interpreted.

The CDC published a paper in 2019 stating that many physicians “were guilty of a misapplication of the 2016 guideline that clamped down on the use of opioids.”

Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control noted that the 2016 guidelines “were essentially taken out of context beyond (their) intent and applied as rigid laws, regulations and policies.”

The guidelines were voluntary. They offered suggestions to help curb the opioid epidemic. They encouraged doctors to try other medications or nondrug options to treat pain rather than turning to opioids as the first treatment option.

Doctors were also urged to limit prescription opioids to three days when treating acute pain. And to prescribe the lowest dose possible.

But in many cases, these suggestions quickly became strict regulations. And the CDC felt the backlash. Many experts say the guidelines are too strict, and they’ve been calling for change ever since.

That change is happening now.

Threading the Needle

The CDC released an update and expansion of the 2016 guidelines. The 229-page document is open for public comment through April 11, 2022.

The update does not include “hard thresholds” from the previous version. Jones noted, “We’ve built in flexibility so that there’s not a one-size-fits-all approach.”

Dr. Joshua Sharfstein is the vice dean for public health practice and community engagement at Johns Hopkins Bloomberg School of Public Health. He explained:

The new recommendations are still voluntary. The document clarifies that these are not prescriptive standards. And that healthcare providers should consider unique circumstances and needs of each patient when prescribing treatments.

The update also avoids language that puts precise limits on dosages and lengths of prescriptions.

So, what do the new guidelines recommend?

New Guidelines for Prescription Opioids: Changes in Store

The updated guidelines provide recommendations for primary care physicians, outpatient clinicians, and other specialty clinicians who are treating three categories of patients:

• Adults with acute pain (lasting less than one month)
• Adults with subacute pain (lasting one to three months)
• Adults with chronic pain (lasting three months or longer)

The guidelines do not apply to patients being treated for cancer or sickle cell disease or receiving palliative or end-of-life care.

The main issues addressed in the guidelines are:

• When to initiate or continue opioids for pain treatment
• Opioid selection, dosage, duration, follow-up, and discontinuation
• Risk assessment/addressing harms of opioid use

Changes made to the previous guidelines include:

• Removal of the suggestion to limit opioid treatment for acute pain to three days.
• Removal of the recommendation that doctors avoid increasing dosage to the equivalent of 90 milligrams of morphine per day.
• Removal of the suggestion to have patients undergo urine testing annually. (But the guidelines still say doctors should consider having patients get tested to see if they are using other drugs.)
• The CDC urges doctors to avoid abruptly halting treatment unless the situation appears life threatening. The agency offers suggestions for tapering patients off the drugs instead.

The main prescribing guideline change is the removal of specific limits on treatment with opioid painkillers. The CDC hopes to avoid any misinterpretation that could prevent patients from receiving needed care.

The new guidelines still emphasize that opioids should not be the first-line option to treat chronic pain. And they advise physicians to start with a low dose of immediate-release pills.

Millions of Lives on the Line

Between spring 2020 and spring 2021, the U.S. saw an astounding 100,306 drug overdose deaths.

An additional study published in February 2020 projected “1.2 million people will die from overdose deaths in the U.S. and Canada through 2029 unless leaders enact evidence-based public health policies.”

Will the changes to the CDC opioid prescribing guidelines improve or worsen these numbers? Are we headed for better pain treatment or an increase in prescriptions that lead to addiction?

Time will tell.

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