DENVER — The CDC’s 2016 opioid guideline is being implemented in ways that harm chronic pain patients, a panel of physicians said here.
At the 2019 American Academy of Pain Medicine (AAPM) meeting, a consensus panel convened by the AAPM Foundation highlighted problems with how the CDC guideline has been applied, raising concerns that it has been interpreted as a regulation and used to impose rigid dose and duration limits.
After the guideline was issued, several states enacted policies to restrict prescribing, and some private insurers limited coverage to control opioid doses.
“A clinician’s ability to make decisions has been severely interrupted,” said Charles Argoff, MD, president of the AAPM Foundation and consensus panel member, in an interview with MedPage Today.
“The recommendations of the guideline itself have not been sufficiently explored with respect to their impact on practicing medicine in the real world,” Argoff continued. “And in many ways, that has led to harm.”
Arbitrary prescribing limits do not benefit all patients, and pain cannot be managed with a one-size-fits-all approach, panelists agreed. But equally important are wider ramifications of the CDC document, several members pointed out.
“My biggest concern with the guideline is that it has been used as an excuse to stop treating pain,” said panelist Karl Haake, MD, an anesthesiologist and pain specialist in Shawnee Mission, Kansas. “We, as healthcare providers, have a moral obligation to treat pain. And treating pain is much more than writing a script for an opioid.”
The CDC guideline also failed to appreciate the importance of involving patients in the decision to taper or discontinue opioids, added panel member W. Michael Hooten, MD, of the Mayo Clinic in Rochester, Minnesota.
Through a consensus report — published in Pain Medicine — the panel aimed to reach policymakers and institutions that influence guideline implementation including regulatory agencies, legislators, public and private payers, and healthcare systems. The report largely supported the CDC guideline, endorsing key points about safety, assessment, and monitoring, but highlighted areas where viewpoints diverged. The report also proposed steps to address unintended consequences of the guideline, including:
- Educating clinicians about the risks of abruptly discontinuing opioids without focused care
- Not misinterpreting the guideline by insisting opioids be stopped or reduced when they are warranted
- Supporting sufficient reimbursement and coverage for comprehensive pain management services, including psychological and physical treatments
“A big issue is the role that insurance companies play in the way healthcare is delivered,” Argoff noted. That in and of itself may dictate how pain medicine is practiced, he said.
“One would want to examine this in more detail, given the sense that healthcare payment entities may play a huge role in access to care,” he added. “We don’t have the freedom to explore what seem to be the best strategies from the guideline.”
The CDC guideline came under fire from another group last week when 300 healthcare professionals, including three former White House drug policymakers, issued a public letter to the CDC saying the guideline is being used by insurers to deny reimbursement and by doctors to turn away patients. The group, called Health Professionals for Patients in Pain, urged the agency to evaluate the guideline’s impact — including its reported effects on patient suicides and increased illicit opioid use — and to issue a “bold clarification” about what the guideline says and does not say, especially about tapering and stopping opioids.
Support for the CDC guideline consensus project of the American Academy of Pain Medicine Foundation was received as unrestricted grants from Collegium Pharmaceutical, Daiichi Sankyo, Egalet, Jazz Pharmaceuticals, Kaleo, and Nektar Therapeutics.
Panel members reported relationships with BioDelivery Sciences, Collegium, Daiichi Sankyo, Egalet, Grunenthal, Kaleo, US WorldMeds, Pﬁzer, Eli Lilly, Novartis, Scilex, Teva, Regeneron, Allergan, Amgen, Jazz Pharmaceuticals, Inspirion, Endo Pharmaceuticals, AcelRx Pharmaceuticals, Intellipharmaceutics, Indivior, Braeburn Pharmaceuticals, Trevena, Franklin Bioscience, Medtronic, Centene Corporation, Abbott Pharmaceuticals, Merck, Purdue, Aetna, and Chrono Therapeutics.