CDC officials say that doctors, insurers, pharmacies and regulators sometimes misapplied the older guidelines, causing some patients significant harm, including "untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and [suicide]," according to the updated guidance.
The 100-page document and its topline recommendation serve as a roadmap for prescribers who are navigating the thorny issue of treating pain, including advice on handling pain relief after surgery and managing chronic pain conditions, which are estimated to affect as many as one in every five people in the U.S.
The fallout, doctors and researchers say, is hard to overstate: a crisis of untreated pain. Many patients with severe chronic pain saw their longstanding prescriptions rapidly reduced or cut off altogether, sometimes with dire consequences, like suicide or overdose as they turned to the tainted supply of illicit drugs.
Federal agencies had tried to course correct, making it clear that the older voluntary guidelines were not intended to become strict policies or laws. But doctors and patient advocates also held out hope that the CDC's updated guidelines would undo some of the unintended consequences of the earlier guidance.
This was clearly on the mind of CDC health officials when they announced the new clinical guidelines on Thursday. (...)
The change in outlook is evident all over the new guidelines, says Dr. Samer Narouze, the president of the American Society of Regional Anesthesia and Pain Medicine.
"You can tell the culture around the 2016 guidelines was just to cut down opioids, that opioids are bad," he says. "It's the opposite here, you can sense they are more caring more about patients living in pain. It's directed more towards relieving their pain and their suffering."
A new focus on individualized care
Opioid prescribing started to decline in 2012 and that trend continued after the 2016 guidelines were released. There's widespread agreement that opioids should be used cautiously because of the risks associated with addiction and overdose. But today, the majority of overdose deaths are not due to prescription opioids, but rather fentanyl and other illicit drugs. (...)
While the voluntary guidelines are a welcome step, their impact depends largely on how state and federal agencies and other authorities respond to them, says Leo Beletsky, professor of law and health sciences at Northeastern University and director of the Health in Justice Action Lab there.
"CDC needs to be a lot more proactive than just putting out this update and trying to walk back some of the misinterpretation of the previous version," he says. The agency needs to work with other federal agencies, he says, including Health and Human Services and the Drug Enforcement Administration, as well as law enforcement to implement these guidelines. (...)
"Most people that I know – and I know a lot of people living with chronic pain – have already been taken off their medication. Doctors are incredibly fearful of prescribing at all." From Steinberg's perspective, the new CDC guidelines remain overly restrictive and won't make much difference to the patients who have already been harmed.
Specific dose and duration limits are out
The most consequential changes in the new guidance come in the form of 12 bullet points that lay out general principles related to prescribing.
Unlike the 2016 version, those takeaways no longer include specific limits on the dose and duration of an opioid prescription that a patient can take, although deeper in the document it does warn against prescribing above a certain threshold. The new recommendations also explicitly caution physicians against rapidly tapering or discontinuing the prescriptions of patients who are already taking opioids — unless there are indications of a life-threatening issue.
Unravelling rigid opioid prescribing policies
It's uncertain if the new guidance will translate into substantive changes for patients who are struggling to have their pain treated.
Many patients currently can't find treatment, in the aftermath of the 2016 guidelines, says Barreveld, because doctors are wary of prescribing at all. (...)
The previous guidelines led to restrictions on prescribing being codified as policy or law. It's not clear those rules will be re-written in light of the new guidelines even though they state they're "not intended to be implemented as absolute limits for policy or practice."
"That is a good idea, and it will have absolutely no effect unless three major agencies take action immediately," says Kertesz. "The DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, all three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality metrics and legal investigation."
by Will Stone and Pien Huang, NPR | Read more:
Image: Jose M. Osorio/Tribune News Service via Getty Images[ed. About time, but too little too late. As a former opioid patient, the hysterics and political grandstanding to do something about the "opioid crisis" have been frustrating to watch and heartbreaking for the thousands if not millions of patients who've been indiscriminately thrown to the curb. Everybody - politicians, hospitals, doctors, insurance companies, federal agencies, media, everybody - should be ashamed of their complicity in inflicting more pain and suffering on chronic pain patients and making the situation worse.]
