New CDC Guidelines Recommend Limits on Prescribing Opioids for Chronic Pain

Increases in opioid prescribing for chronic pain and the epidemic of opioid use disorder and overdose death underscore the need for safer prescribing practices. The US Centers for Disease Control and Prevention recently released opioid prescribing guidelines aimed at primary care clinicians treating adults with chronic non-malignant pain, citing a lack of evidence for long-term (> 1 year) benefits and evidence of possible harms from opioids, as well as benefits of non-pharmacologic and non-opioid pharmacologic therapy. Recommendations were provided in 3 areas:

• Opioid initiation and continuation: preference for non-pharmacologic treatments and non-opioid medications, establishment of goals, and discussion of risks and benefits.
• Opioid selection, dose, duration, follow-up, and discontinuation: begin with short-acting opioids at lowest effective dose, limit acute pain treatment to 3–7 days, and assess benefits and harms regularly, discontinuing opioids if harms outweigh benefits.
• Assessing risks and addressing harms: evaluate and mitigate overdose risk by offering overdose education and naloxone, performing urine drug screening and prescription drug monitoring program checks, avoiding concurrent benzodiazepines, and assuring agonist treatment for opioid use disorder.

Comments:

While most recommendations are becoming best practices in opioid prescribing, the potential regulatory role of a federal guideline published initially in the Federal Register raises questions about how insurers and regulators might use it to limit access to opioid treatment. Given the admittedly scant evidence supporting the recommendations, this guideline should be viewed more as a response to a public health crisis than a set of evidence-based clinical practices.

Joseph Merrill, MD, MPH

Reference:

“CDC guideline for prescribing opioids for chronic pain — United States, 2016.” Morbidity and Mortality Weekly Report. 2016;65.

Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. JAMA. 2016;315(15):1624–1645.