Finally: Some common sense from CDC on opioids
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ederal health officials on Thursday abandoned their influential recommendations that opioid prescribers should aim for certain dose thresholds when treating chronic pain.
The changes came as part of a proposed update to the Centers for Disease Control and Prevention’s controversial 2016 guidelines on opioid prescribing. The recommendations are an attempt from health officials to strike a balance between limiting the harms that can come from long-term opioid use; allowing for physicians to come up with individualized plans to treat their patients; and encouraging reductions in dosages when it can be done safely and with patient buy-in.
The newer guidelines still say that “opioids should not be considered first-line or routine therapy for subacute or chronic pain” and note that other treatments are often better for acute pain as well. Doctors should prioritize non-opioid medications and interventions like exercise and physical therapy, according to the recommendations.
Gone, however, is language that says doctors should “avoid increasing dosage” to 90 morphine milligram equivalents or more per day or to “carefully justify” such a decision. The CDC guidelines were always meant to be voluntary, but policymakers sometimes interpreted the 90 MME figure as a hard ceiling for what doctors could prescribe — even though many chronic pain patients were already on higher dosages.
In many ways, the proposed changes to the guidelines are a victory for experts and patient advocates who have argued for years that despite the CDC’s intentions, the guidelines were resulting in physicians unsafely tapering patients or cutting patients off entirely — in part because of the specific dosage benchmarks included in the guidelines.
The 2016 guidelines became a major flashpoint in the ongoing — and often contentious — debate over how tightly to limit the opioid prescribing patterns that helped ignite the country’s overdose crisis, and the unintended harms being imposed by those efforts. Experts disagree over whether opioids should be used as a chronic pain treatment broadly at all. Doctors who encourage patients to try to lower their doses point to various harms from long-term, high-dose opioids — not just the risk of addiction and overdose, but possible mental health consequences and perhaps even worse pain sensitivity.
Opioid prescriptions have been falling since 2012, as the medical community realized it needed to reassert control over how laxly the medications had been prescribed. The declines accelerated after the publication of the 2016 guidelines.
