New Guidelines on Opioid Prescriptions

The Centers for Disease Control and Prevention is removing its previous recommended ceilings on opioid doses and encouraging doctors to use their best judgment, after complaints from patients and providers who found the guidelines too restrictive.

The agency says its new guidelines are voluntary and intended to be flexible to support, not supplant, clinical judgment. CDC emphasizes “this clinical practice guideline should not be applied as inflexible standards of care across patient populations by healthcare professionals, health systems, pharmacies, third-party payers, or state, local, and federal organizations or entities.”

Dr. Samer Narouze, president of the American Society of Regional Anesthesia and Pain Medicine, told the New York Times he is pleased with the tone, level of detail, and focus of the new recommendations. “It’s a total change in the culture from the 2016 guidelines,” he said, characterizing the earlier edition as ordering doctors to “just cut down on opioids — period.”

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For instance, the 2016 guidelines specified hard thresholds like 90 morphine milligram equivalents, and noted most patients could get by with taking opioids for three days while “more than seven days will rarely be needed.” Consequently more than half the states passed laws that limited initial opioid prescriptions to seven days or less, and many states limited pain-medication refills for Medicaid enrollees. Private insurers and pharmacies also curtailed opioid prescriptions.

Nevertheless, the new guidelines emphasize nonopioid therapies are effective for many common types of acute pain and found insufficient evidence to determine long-term (>1 year) benefits of opioid therapy for chronic pain. “Before starting opioids for subacute or chronic pain, clinicians should discuss with patients the known risks and realistic benefits of opioid therapy, work with patients to establish treatment goals for pain and function and consider how opioid therapy will be discontinued if benefits do not outweigh risks,” the guidelines say.

The guidelines, which are open for public comment on the Federal Register, address 1) determining whether or not to initiate opioids for pain; 2) opioid selection and dosage; 3) opioid duration and follow-up; and 4) assessing risk and addressing potential harms of opioid use. The CDC will likely issue a final version by end of the year.

Kate Nicholson, executive director of the National Pain Advocacy Center, is among the many observers pleased with the balance struck by the new guidelines. “We went from one side of the pendulum, with overly liberal prescribing of opioids, and that did harm, to just looking at gross drops in prescribing without looking at individual needs. And that did harm,” she commented to the New York Times.