CDC Opens Draft Opioid Guidelines for Public Comment

CDC Director Tom Frieden

CDC Director Tom Frieden

The Centers for Disease Control and Prevention this month released its draft guidelines for the prescribing of opioid pain medications for chronic pain.

The recommendations are designed for primary care settings, and focus on chronic pain lasting longer than three months. They do not apply to palliative or end of life care. They were published on Dec. 14 and will be open for public comment until Jan. 13, 2016.

In its public notice the CDC stated, “The guideline is not a federal regulation; adherence to the guideline will be voluntary.” However, the American Medical Association and others noted that the guidelines would likely have significant public impact. For example, a new federal law requires the Veterans Administration to adopt the final CDC guidelines as official policy.

Here’s an outline of the CDC’s draft recommendations:

  1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are “preferred” for chronic pain.
  2. Providers should establish treatment goals before starting opioid therapy for chronic pain.
  3. Providers should discuss the risks and “realistic benefits” of opioid therapy before starting opioid therapy, and periodically thereafter.
  4. Providers should prescribe immediate-release opioids for chronic pain, instead of extended-release opioids.
  5. Providers should start with the “lowest effective dosage.”
  6. For acute pain, providers should prescribe the “lowest effective dosage” for immediate-release opioids, and should prescribe “no greater quantity than needed for the expected duration of pain severe enough to require opioids. It states, “three or fewer days usually will be sufficient for most non-traumatic pain not related to major surgery.”
  7. Providers should evaluate the benefits and harms of with patients within 1 to 4 weeks of starting opioid therapy.
  8. Providers should evaluate risk factors for opioid-related harms before starting or continuing opioid therapy. These risk factors include the patient’s history of overdoses and/or history of substance abuse disorder.
  9. Providers should review the patient’s prescription history using the state prescription monitoring program when starting therapy, as well as periodically during therapy.
  10. Providers should use urine drug testing before starting opioid therapy for chronic pain, and should consider ordering such tests annually.

There have been strong reactions to the guidelines, focusing on both the content and the process under which the guidelines were developed.

The CDC did not originally plan to accept public comments before finalizing the guidelines, but the American Medical Association and other groups have criticized a “lack of transparency” in the drafting process.

An AMA letter to the CDC in October also stated the guidelines are “devoid of a patient-centered view and any real acknowledgement or empathy of the problems chronic pain patients may face.”

The House Committee on Oversight and Government Reform has also launched an investigation into the drafting process.

As of Dec. 30, the CDC’s website had collected more than 1,300 public comments. The AMA is expected to submit comments on the current draft in early January.

Background information

  1. Bruce Bodner says:

    Do not some physicians feel the need to supply opiates to keep the patients happy? After all, an unhappy patient (one who is denied opiates) is more likely to sue. I don’t see any push for liability reform as part of the opiate control effort. So on one hand the state is trying to curtail inappropriate opiate use, but through the court system it can deliver a profound disincentive for the doctor to take any action which would anger the patient. Of course, the pure restriction on inappropriate opiate use alone will not (probably) be enough to convince a jury that malpractice has occurred. But we all know that small slights, errors, omissions, misdiagnoses, unanticipated or unfortunate outcomes can be either accepted by a patient with effort and goodwill on the part of the physician, or lead to a multimillion dollar judgement if the patient is angry and the lawyer avaricious (an oxymoron, I know).
    Sadly, not only is there no sign of this dynamic being addressed, the government is doubling down on the incentive for opiate abuse by increasing the role that patient satisfaction plays in physician reimbursement. (see HCAPHS)
    I am reminded of the cynic inducing dichotomy that the federal government plays with calories. On one hand through the Surgeon General’s office, the First Ladys “Let’s Move” initiative, the provision for labeling and restaurant regulation in the ACA, they are “combating the obesity epidemic”. On the other hand they subsidize corn, sugar, they have tripled the food stamp expenditure in the past 10 years !
    I do wish that our organizations would point these glaring facts out instead of just advocating for minor adjustments to the wrong headed policies that the government bureaucrat/politicians just love to churn out.

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