CDC Clarifies Opioid Prescribing Guidelines

When the Centers for Disease Control and Prevention (CDC) released its “Guideline for Prescribing Opioids for Chronic Pain” in 2016, the intent was to provide recommendations to prescribers who would then apply the recommendations to the care of their patients on a case-by-case basis. Since then, policies and practices emerged that interpret the guideline as a hard-and-fast rule, in effect encouraging abrupt tapering and sudden discontinuation of opioid medications, including those used in medication-assisted treatment (MAT) for opioid use disorder. Reports began to surface in the media of patients being cut off from opioid medications with little to no support and turning to street drugs to get relief of chronic pain or opioid withdrawal, sometimes with fatal consequences—outcomes the CDC neither promoted nor intended.

In a commentary in The New England Journal of Medicine (NEJM), the authors of the original guideline addressed these reports and the ways the guideline has been misapplied, clarified the guideline’s key points, and reiterated CDC’s original intent. Deborah Dowell, M.D., M.P.H., and colleagues stated that misapplying the recommendations to populations that fall outside the scope of the guideline (for example, patients with pain associated with cancer, surgical procedures, or acute sickle cell crises) and to the dosage of opioid agonists used in MAT is “likely to result in harm to patients.”

The authors also clarified the oft-misinterpreted recommendation that clinicians avoid increasing opioid dosage to ≥90 morphine milligrams equivalent per day, which has prompted de-prescribing and rapid tapering by some clinicians and served as the basis for prior authorization and claims denials by insurance companies.

“This [recommendation] does not address or suggest discontinuation of opioids already prescribed at higher dosages … [or] apply to dosing for medication-assisted treatment for opioid use disorder,” the authors wrote. Other key points in the commentary include the following:

• Policies should allow clinicians to make clinical decisions according to each patient’s unique circumstances.

• Although some situations such as a nonfatal overdose may necessitate rapid tapers, the guideline does not support stopping opioid use abruptly.

• Dismissing patients from care can adversely affect patient safety, represents patient abandonment, and results in missed opportunities to provide potentially lifesaving information and treatment.

APA CEO and Medical Director Saul Levin, M.D., M.P.A., welcomed the commentary by Dowell and colleagues. “It is important to ensure that we balance the treatment needs of patients with pain with our response to the opioid crisis. We were concerned about how the guideline would be implemented when it was released, and we’re glad the CDC is taking action to ensure that pain patients have access to critical medication,” Levin said.

Andrew Saxon, M.D., past chair of APA’s Council on Addiction Psychiatry, agreed, stating that the NEJM commentary “provides a much-needed corrective to the overreaction to concerns about opioid prescribing and the opioid epidemic that has harmed some of the ‘legacy patients’ who, through no fault of their own, ended up on long-term opioid treatment and [now] face challenges reducing their opioid dosages.”

“It is going to take some concerted education to get back on a reasonable course for the legacy patients. Until we have better evidence on how to manage them, care for each one has to be individualized,” Saxon told Psychiatric News. Saxon advised psychiatrists who work in pain management not to start opioid-naïve patients with chronic pain on opioids unless all other avenues of treating the pain have been exhausted. He also discouraged forced tapers for legacy patients to reach a specific dosage.

“Some of these patients will need to remain on higher dosages; some can undergo very slow, modest dose reductions; and some may need to be treated for opioid use disorder,” Saxon said. He added that psychiatrists in pain management should be trained and prepared to treat opioid use disorder with buprenorphine. “High demand exists for this treatment, and psychiatrists can deliver it particularly well because of their combined pharmacotherapy and psychotherapy skills.” ■