CDC Tries Less Rigid Approach to Opioid Prescribing Guidelines

By Jonathan Springston, Editor, Relias Media

The CDC updated its clinical practice recommendations for prescribing opioids this week. Although there appear to be no major deviations from the 2016 guidelines, the agency seems to have tried a more nuanced approach in its latest revisions.

The 2022 recommendations are built on four pillars. According to the CDC, clinicians should determine whether to initiate opioids for pain. If so, select the right opioid at the appropriate dose. Decide the duration of the first prescription and set a timetable for follow-up. Finally, assess the risk and address potential harms of using opioids.

Around these four pillars, the CDC offers 12 recommendations. Above all, clinicians should first try non-opioid therapies to manage pain. However, if opioids are necessary, the CDC recommends sticking with low doses for short periods, with proper patient education, close monitoring, and frequent follow-ups.

Much of the 2022 recommendations appear to be largely unchanged from 2016; however, the biggest difference now seems to be the way the agency went about revising the guidelines and how it is communicating the information to the public.

Softer language appears throughout the agency’s communication this week, such as “recommendations should not be applied as inflexible standards of care across patient populations” and guidelines “should not be used as an inflexible, one-size-fits-all policy or law or applied as a rigid standard of care or to replace clinical judgment about personalized treatment.”

In a perspectives article published in a medical journal this week, Debbie Dowell, MD, MPH, chief clinical research officer for CDC’s Division of Overdose Prevention, and colleagues explained in more detail what was problematic about the 2016 guidelines. “The guideline’s release was associated with accelerated reductions in overall and potentially high-risk prescribing of opioids and with increases in prescribing of nonopioid pain medications,” Dowell and colleagues wrote. “Concurrently, new laws, regulations, and policies, in some cases purportedly derived from the 2016 guideline, went beyond — and were inconsistent with — its recommendations. Such misapplication, including inflexible application of recommended dosage and duration thresholds, contributed to patient harms, including untreated and undertreated pain; rapid opioid tapers; and abrupt discontinuations, acute withdrawal symptoms, and psychological distress, in some cases leading to suicidal ideation and behavior.”

Dowell and colleagues noted how multiple peer reviewers, an independent advisory group, and ordinary citizens reviewed and commented on the 2022 draft recommendations. It was during this review process the agency heard feedback about possibly “inflexible standards” and omissions of key material. In response, in the 2022 guidelines, the CDC included “supporting text following each recommendation” and “more specific information, including data related to dosages, to inform clinical decision-making and individualized patient care.”

“The 2022 guideline aims to promote equitable access to effective, informed, individualized, and safe pain management that improves patients’ function and quality of life, while clarifying and reducing the risks associated with opioid use,” Dowell and colleagues wrote. “Ideally, new recommendations should result in greater and more equitable access to the full range of evidence-based treatments for pain, more judicious initial use of opioids, and more careful consideration and management of benefits and risks associated with continuing, tapering, or discontinuing opioids in patients who are already receiving them long term.”

For more on this and related subjects, be sure to read the latest issues of Healthcare Risk Management, Internal Medicine Alert, and Medical Ethics Advisor.