The CDC’s New Guidelines For Prescribing Opioids
This week, the Centers for Disease Control and Prevention (CDC) presented a set of recommendations for Opioid prescriptions. These new guidelines are the first revisions made to the organization’s 2016 suggestions which stopped many with chronic pain from getting the relief they needed.
The Opioid Epidemic And The CDC
For over 3 decades, the US has been experiencing a serious public health crisis known as the Opioid epidemic. In the 1990s, pharmaceutical companies, insurers, and pain specialists endorsed Opioid pain relievers as being less addictive and safe to use for common ailments. The marketing of drugs like OxyContin led to an increase in prescriptions being written for issues like backaches and arthritis.
As a result, US overdose deaths rose drastically. From 1999 to 2017, Opioid-related overdose deaths increased almost sixfold. While local and federal governments attempted to restrict prescriptions, the crisis continued. Those who had already become addicted to Opioids turned to Heroin or Fentanyl when they couldn’t get a prescription. In fact, studies have shown that 80% of people who have used Heroin first used prescription Opioids.
The CDC released a set of guidelines in 2016 aimed at decreasing the number of Opioids being prescribed. The organization urged physicians to explore other treatment options before turning to Opioids. Other medications and non-drug therapies were recommended as alternatives. If doctors chose to prescribe painkillers for acute pain, the CDC proposed a 3-day limit for prescriptions and that doctors prescribe the lowest possible effective dose. These guidelines also applied to treating chronic pain. Despite being voluntary, doctors and local governments implemented these recommendations.
An Unintended Consequence
Although these guidelines ultimately contributed to a decrease in Opioid prescriptions being written, they were largely opposed due to their effect on a specific group. Many doctors across the US feared there would be criminal or civil consequences if they did not follow them. Doctors became very hesitant to prescribe Opioids and quickly tapered patients off of their prescriptions. This greatly affected many chronic pain patients who rely on doses higher than the 90 milligram ceiling of Morphine listed in the 2016 guidelines.
Studies have shown that rapid tapering patients off of Opioids can lead to harmful outcomes. One particular study of 100,00 chronic pain patients found there was 68% increase in overdose deaths for patients experiencing tapering compared to those who were not. For the tapered group, there was also a spike in mental health conditions. Chronic pain patients were also more likely to turn to substances like Heroin and Fentanyl to self-medicate their pain after being tapered off their medications. Suicide can also be an outcome of tapering. It has been reported that up to 30% of Opioid overdoses could be suicides.
The rigid interpretation of the CDC’s 2016 guidelines also affected those who were struggling with a substance use disorder (SUD). Many doctors developed a one strike policy. This meant that if a patient tested positive for an illicit substance, they were not given further treatment.
CDC Proposes New Guidelines
Several organizations spoke out against the original 2016 guidelines. In 2019, the US Food and Drug Administration issued a warning about the dangers that can come from suddenly tapering patients off of Opioids. The American Medical Association recommended that doctors immediately suspend the CDC’s guidelines in 2020. In response, the CDC acknowledged that their suggestions had been misinterpreted and misused. Concerned about the reports of people with chronic pain being denied relief, the CDC began to work on revisions to their 2016 guidelines. This time, their recommendations were drafted with no input from drugmakers.
The new guidelines, released on Thursday, are aimed at balancing the necessary use of Opioids for severe pain and protecting other patients against harmful risks. The 12 recommendations proposed in the 229 page document changes the “one-size fits all approach” to Opioid prescriptions. Doctors are being urged to look at each patient’s situation and assess the risk and benefits prescribing Opioids. Overall, the CDC still believes that non-Opioid therapies should be attempted before prescribing Opioids for pain. At the same time, they removed the 90 milligram ceiling of morphine for chronic pain patients and the 3 day limit for acute pain.
While the document warns of addiction, depressed breathing, and effects to mental status, they have noted that they serve a very important medical purpose. Relieving pain from traumatic injuries, such as burns and crushed bones, were listed. In these cases, it is recommended that immediate release pills be used rather than long-acting. The CDC also stated that these guidelines do not apply to those with cancer, sickle cell, and end of life or palliative care.
The CDC also noted that patients who come in and test positive for illicit substances could have untreated pain or a substance use disorder. The new guidelines recommend that doctors offer treatment, counseling, and careful tapering when necessary. In doing so, they can assist patients in improving their quality of life.
These recommendations are currently available on the Federal register. For 60 days, the public can make comments on the proposed guidelines. The CDC will then review these comments and will likely release a final issue by the end of the year.