Amid backlash from chronic pain sufferers, CDC drops hard thresholds from opioid guidance

New guidance on prescribing opioids unveiled Thursday by the Centers for Disease Control and Prevention avoids the strict limits found in a 2016 version that accelerated a nationwide drop in pain pill prescriptions but led to backlash from chronic pain patients. 

The 229-page document advises doctors to limit new opioid prescriptions and discuss alternative therapies with patients. But the new guidance largely avoids figures on dosage and length of prescription and warns against abruptly or rapidly discontinuing pain pills for some chronic pain patients.

"We've built in flexibility so that there's not a one-size-fits-all approach," said Christopher Jones, acting director of the CDC's National Center for Injury Prevention and Control. 

The document includes a dozen recommendations on how and when to manage pain patients, including non-pain-pill therapies, for people in non-hospital settings. Just as important, it does not include the "hard thresholds" from the 2016 version that "were essentially taken out of context beyond (their) intent and applied as rigid laws, regulations and policies," Jones said. 

The new guidance, available for the public to review and comment on over the next 60 days, is for doctors and non-physician prescribers who treat three categories of patients: adults with acute pain lasting less than one month; "subacute" pain for one to three months; and chronic pain for three months or longer. It does not apply to sickle cell disease, cancer, palliative or end-of-life care. 

For patients who have not taken opioids before, doctors should prescribe the lowest dosage. For patients with chronic pain, prescribers should be cautious about recommending opioids and gauge the risks and benefits, the guidance says. 

Doctors and other clinicians should recommend pain pills for chronic pain patients only if expected benefits and ability to do everyday tasks outweigh known risks, which can include addiction, overdose, heart trouble, broken bones or falls.

Doctors also should discuss risks and benefits and should consider how opioid prescriptions will be discontinued.

For patients already on higher dosages, clinicians should rely on other therapies and try to gradually lower dosages or discontinue opioids. However, unless there's a life-threatening issue such as signs of overdose, doctors should not abruptly discontinue or rapidly reduce opioid dosages, the guidelines say.

"They are trying to thread a needle here," said Dr. Joshua Sharfstein, a Johns Hopkins Bloomberg School of Public Health vice dean for public health practice and community engagement. "They're trying to balance, on the one hand, the importance of clear guidance to clinicians, and on the other, the danger it could turn into

a rigid policy that undermines patient care."

After the 2016 guidelines were released, more than half of states passed laws that limited initial opioid prescriptions for acute pain to seven days or less. Many states limited pain pill fills for Medicaid enrollees, and private insurers and pharmacies also curtailed opioid prescriptions. Some states enacted strict limits on doses, prompting doctors to aggressively taper patients who had been on opioids for years, and medical boards sanctioned doctors who ran afoul of the tighter requirements. 

Under the old recommendation, chronic pain patients complained of being cut off from pills they had taken for months or even years. Some in the middle of cancer treatments or recovering from operations could not get pain medications.

After the earlier guideline, a non-peer-reviewed survey of more than 3,000 patients found 84% reported more pain and worse quality of life, and 42% said they had considered suicide.

Amid backlash from chronic pain patients and their allies, federal officials said doctors were misusing the 2016 opioid pain medication guidelines. In a 2019 paper published in the New England Journal of Medicine, the CDC said many physicians were guilty of a "misapplication" of the 2016 guideline that clamped down on the use of opioids.

More:Pain patients left in anguish by doctors 'terrified' of opioid addiction, despite CDC change

In a nod to the earlier controversy, the new report said prescribers should avoid “misapplying” the new guidance and not implement policies “that result in unintended consequences for patients.”

The guidelines warned against being “inflexible” on the dose and duration, doctors no longer seeing chronic pain patients, or cutting back on dosages for stable patients without discussing it with them. 

The report also noted disparities in care based on race and geography, with Black opioid users less likely than whites to be referred to pain specialists. And rural residents are significantly more likely to be prescribed opioids when non-opioid treatments might be preferred, the report said. 

 "We see continued long-standing disparities in access to pain care or the types of care that might be provided, in particular among racial ethnic minority populations who often are not provided pain care at the same level," the CDC's Jones said. 

Pain pill prescriptions drop, overdose deaths surge

Opioid prescriptions began declining in 2012, and the drop accelerated after the 2016 guidance was adopted. Still, the number of overdose deaths has continued to rise as people increasingly turned to heroin and, more recently, illicitly manufactured fentanyl, often cut with street drugs such as methamphetamine. 

More than 100,000 Americans died of drug overdoses in the 12 months after the COVID-19 lockdowns, the most overdose deaths ever recorded in a one-year span, according to the CDC.

The 100,306 drug overdose deaths during the 12 months ending in April was a jump of 28.5% from the 78,056 deaths during the same period one year before and more than double the number of deaths each year from vehicle crashes, according to the most recent National Center for Health Statistics estimates released by the CDC in November.

Some project those drug deaths will continue to rise. A study published this month in The Lancet projected 1.2 million people would die from overdose deaths in the U.S. and Canada through 2029 unless leaders enact evidence-based public health policies.

Keith Humphreys, a Stanford University psychiatry and behavioral sciences professor who chaired a commission that published the Lancet study, said it's important to tailor policies to a patient's individual circumstances rather than adopt a blanket approach for all. 

"The commission absolutely did not endorse unilaterally kicking pain patients off their medication, which can cause significant harm," Humphreys said. "Our focus was on evidence-based opioid stewardship, which is much more about not putting new patients on opioids in the first place" and helping existing opioid patients taper to lower doses.

More:Drug overdoses surged amid COVID lockdowns; more deaths in one year than ever before

The Biden administration has sought to curb the addiction epidemic with a four-part strategy that aims to slow the nation's spiraling overdose deaths.

The plan seeks to prevent substance-use disorder, expand medication-assisted treatment for people with opioid addiction, and support people in recovery from addiction. The plan also makes the opioid overdose-reversal drug naloxone widely available, expand access to test strips that can detect fentanyl, and support programs that supply clean needles to prevent the transmission of HIV and hepatitis C. 

Ken Alltucker is on Twitter as @kalltucker or can be emailed at alltuck@usatoday.com.