Eight times, “patient abandonment”, is mentioned in the revised and expanded pain management guidelines released today by the Centers for Disease Control and Prevention. They also include two occurrences of this admonition, in bold and italics: “The best thing for patients is to be seen by a doctor.“
This will give you an indication of the devastating impact the original version from the CDC on medical care, which was published in 2016. It is clear that something has gone horribly wrong. Clinicians must be reminded of the fact they cannot abandon patients. The CDC acknowledges the issue and shows its readiness to fix the problems caused by 2016 guidelines. These policies resulted from undertreatment, dangerous “tapering” pain medications, denials of care, procrustean policies, and a preference for opioid prescribing reductions over patients’ interests.
Original guidelines were written for primary care physicians. They focused on the “prescription of opioids for chronic pain” and warned about the dangers associated with exceeding 90 milligram equivalents of morphine (MMEs). That threshold was viewed by legislators, doctors, pharmacists, regulators and insurers as a hard limit. This means that patients suffering from chronic pain should adhere to the arbitrary limit.
While the guidelines for 2016 were focused on chronic pain they did not ignore acute pain. “Long-term opioid use often starts with acute pain treatment,” said the CDC. The CDC stated that a prescription lasting three days or less is sufficient for acute pain. A prescription of more than seven days is rare. According to the CDC, more than half of the states have now passed laws that limit the initial prescription for pain medication. This includes “more pharmacies, insurance benefit managers and pharmacists.”
The guidelines are merely advisory. However, in reality, the guidelines were often mandatory for patients.
The CDC states that some policies, purportedly taken from 2016 CDC Guideline, have been notably inconsistent and go well beyond its clinical recommendations.” In the updated guidelines, the CDC still has drafts available for public comment. “Such misapplication includes extension of the 2016 CDC Guideline to patient populations not covered in the 2016 CDC Guideline (e.g., cancer and palliative care), opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the Guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment…duration limits by insurers and by pharmacies, and patient dismissal and abandonment.”
In practice, what did “misapplication” mean? According to the CDC’s notes, the Food and Drug Administration has warned that opioid dependence can lead to severe withdrawal symptoms and exacerbations of pain.
The CDC refers to the FDA’s “safety alert” issued in 2003 to address complaints by patients and specialists. The FDA warn did not mention suicide but the completion of this act. If patients resort to suicide as a response to CDC-inspiring medical procedures, then it is time for the FDA to acknowledge that they did not adequately consider the possibility of unintended and foreseeable consequences.
This is something that the CDC has not admitted in its new guidelines. However, it made many notable modifications to dissuade “misapplication”
According to the CDC, “This voluntary clinical practices guideline does not require compliance.” Federal Register announcement. The clinical practice guideline was created to allow for flexibility so that it can support and not replace clinical judgements.
Revisions to the guidelines include 12 key recommendations. These are general tips for clinicians. These guidelines do not cover “sickle-cell disease-related pain management”, cancer pain treatment or palliative and end-of life care. While the advice is still biased against opioid treatment, it doesn’t mean that more than 90mg per day for chronic pain is inherently dangerous. The CDC stresses the need to work with patients and tailor treatment. The CDC states that the calculus does not just include the pros and cons, but also includes the potential dangers associated with abrupt dosage reductions.
The CDC states that “payers and healthcare systems shouldn’t use this clinical guideline to establish rigid standards regarding the duration or dose of opioid therapy.” They also “should make sure policies based upon cautionary dosage thresholds don’t result in abrupt withdrawals or rapid tapering of opioids.” Clinicians should weigh the risks and benefits of lowering or maintaining opioid doses for patients who have been prescribed higher dosages. If the risks are greater than the benefits, physicians should consider other treatments and collaborate with patients to reduce opioid dosages. Or, depending on individual patient circumstances, discontinue opioid therapy. Opioid therapy should never be stopped abruptly unless there is a risk of serious complications, like confusion or slurred speech.
These warnings, if they are overdue, are appreciated but it’s not clear exactly what “work” is.[ing]This is how it should be done. The CDC states that while some experts believe that it is important to obtain informed consent before tapering opioids, others feel that informed discussions are more appropriate than informed consent. This is because clinicians have an overriding responsibility not to harm patients.
The CDC has not issued any new warnings about chronic pain prescribing greater than 90 mg of ME per day. The CDC suggests that the daily maximum prescribed dose for acute pain should be 50mme per day. “Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day but are exposed to progressive increases in risk as dosage increases,” it says. “Therefore, before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks. The clinician should be cautious when increasing the dosage.
The CDC is aware of the concerns that such guidance could result in suboptimal care or misguided policy making, just as it did with its prior emphasis on the 90MME/day threshold. The CDC’s response is to remove any mention of the 50-MME/day threshold in its highlighted recommendation and relegate that discussion to “implementation considerations”. Lynn Webster is a former President of the American Academy of Pain Medicine. She notes that the CDC doesn’t acknowledge the weak scientific foundation for MME thresholds. These thresholds don’t take into consideration wide variations in patients’ metabolites and responses to pain medications.
The CDC strongly believes that pain should be treated with non-opioid medications whenever possible. It acknowledges, however that nonsteroidal antiinflammatory drugs (NSAIDs), such as ibuprofen can have risks and not offer adequate relief. Although nonpharmaceutical options may be viewed as too optimistic by some pain specialists, they are not required to replace opioids.
The CDC states that opioids should not be used as a first-line treatment for chronic or subacute pain. Patients should not be required or required to undergo non-opioid and nonpharmacologic therapy prior to starting opioid therapy.
The CDC no longer suggests that prescriptions of opioids for acute pain should last more than a week. It now says, “a few days.”
While “less is often enough,” the CDC recommends that patients take less than the recommended dose. However, each patient’s clinical situation should dictate the duration of treatment. The CDC suggests starting at the lowest dose possible, avoiding prolonged-acting formulas and instructing patients not to prescribe more than they might actually need.
Although these recommendations seem simple, there are tradeoffs. According to the CDC prescriptions should only be prescribed for “the anticipated duration of severe pain sufficient to warrant opioid treatment.” It acknowledges, however that not all “expected lengths” are the same. For example, a patient who takes hydrocodone following surgery or an injury may still be in pain when his prescription runs out. Because the CDC wants to prevent unused medication from being diverted for non-medical purposes, it will allow such patients to suffer while they wait to receive a prescription.
The CDC states that “to minimize the unintended consequences on patients experiencing severe acute pain for an unexpectedly long duration,” clinicians, health system staff, and practices should be able to provide prompt re-evaluation of those patients who have severe acute pain. This will allow them to revise or confirm the original diagnosis, adjust their management, and ensure they are not left in pain. To minimize the disparities in patient care based upon access to, affordability, and refills of care, clinics, hospitals, and health system should all ensure that patients are able to access additional evaluations as necessary.
This seems like too much wishful thinking. Patients will still suffer unrelieved pain even if these “mechanisms are in place”. Unacknowledged, there is a value judgment that the war against drugs should prevail over patients welfare.
Similar to the CDC’s statement that “opioids should not be used as first-line treatment” in patients who have had dental surgery. This is done to avoid unnecessary opioid prescriptions which could lead to “misuse” of the drug. This goal is not possible if many patients find Tylenol/Advil inadequate.
The CDC’s bias towards opioids doesn’t seem to be justifiable given the risk of addiction it highlights. In 2015, according to the National Survey on Drug Use and Health, nearly 100 million Americans used prescription opioids, including nonmedical users as well as bona fide patients. Judging from their responses to survey questions, about 2 million of them, slightly more than 2 percent, qualified for a diagnosis of “substance use disorder”—a catchall category that subsumes what used to be known as “substance abuse” and the more severe “substance dependence”—at some point during the previous year. Data from the survey show that 9 per cent of drinkers in past years had an alcohol-related disorder in 2015.
Fatal overdoses do not occur as often as the CDC claims. A 2015 study of opioid-related deaths in North Carolina, reported in Pain MedicineAccording to Webster, 478 people died from opioid-related causes in 2.2million residents. This was an increase of 0.022 per cent. Webster notes that the CDC dubiously blames opioid prescribing for increases in drug-related deaths between 1999 and 2010 without acknowledging that the upward trend in fatalities accelerated after the government succeeded in reducing the use of opioid pain medication. Opioid prescriptions declined, and opioid-related fatalities, mostly heroine and illicit fentanyl rose to records.
Even though the CDC acknowledges the need for opioids, it may not be clear that this message is being received amid its many warnings about their dangers. According to the CDC, opioid therapy is important for severe traumatic injuries such as crush injuries or burns. It can also be used to treat severe acute pain after invasive surgery when NSAIDs are not recommended. However, The New York TimesAccording to reports, the guidelines discourage prescribing opioids for trauma injuries such as burns or auto accidents. You can contact us if you have any questions. TimesJan Hoffman, a health reporter, got the impression that clinicians could also get this impression. This leads to more “misapplications” of the CDC’s advice.
However, overall, these guidelines offer a vast improvement to the 2016 recommendations by the CDC. Kate Nicholson is president of National Pain Advocacy Center. She says, “The framing has improved.” Her observations include “a greater emphasis being placed on treating pain, individualization and patient-centered care as well as disparities in care.” [the point]The guideline is not meant to be used in place of clinical judgement or as a basis for policy. She adds that “the two provisions that wreaked the most havoc—the day and dosage thresholds—have been removed from the actual recommendations.”
Nicholson has her own concerns. Nicholson also has concerns. She says that MME thresholds still need to be considered and should not be re-examined. Policy makers could “still lift them.” Her suggestion that the MME thresholds be extended to shorter-term pain would “open a can of beans and confuse more than it clarifies.” Although “a lot of things have improved,” she said, “a lot more needs to be done.”
Bob Twillman (ex-executive director of Academy of Integrative Pain Management) also supported many of the CDC changes. He told Pain News Network that the wording in the recommendations was much better than the one from 2016. “It is especially welcome to eliminate specific dosage numbers, as they were easy for payers and policymakers to grasp onto when setting policies.
Twillman stated that while “it’s great that they’re removing them”, he said that “I fear it’s almost like closing the barn doors after the horse has fled.” It is necessary to change or remove policies tied to specific numbers from the 2016 guideline. I would like to see the CDC take part in this work.
Webster was less pleased with the CDC’s recent changes. Webster says that the CDC’s changes have been less impressive than he expected. He said, “The positive thing” is that there were no explicit dosage limits and opioid supplies for acute pain are now not limited. He notes that although they state the guideline shouldn’t be an inflexible standard for care that is imposed upon specific populations, they don’t explicitly say that policymakers and law enforcement should use it to establish a standard or prosecute providers.
Webster wonders why the CDC feels the need to provide pain relief advice for doctors. Webster says this task should “be left to professional associations.” “Several experts in the field predicted the outcome of the 2016 CDC guidelines before they were issued.…The debacle with the 2016 CDC guidelines [illustrates]This is why the CDC cannot dictate how pain medicine should work.