Will the updates be enough?

A look at early comments from the Opioid Task Force on the CDC’s updated guideline and how some states are developing their own opioid prescribing rules.

Even before its publication five years ago, the CDC’s guidelines for prescribing opioids for chronic pain1 was at the center of the controversy, with pain advocates and practitioners concerned that the recommendations might be misinterpreted by policymakers as black and white rules with no room for individualized care and professional judgment. In the years that followed, these fears were often proven to be true.2 Countless state legislatures and licensing boards have adopted parts of the directive as law, as opposed to recommendations, and generally have done so in a way that ignores the nuances and flexibility of the directive. underlying in favor of strict dosage caps and duration limits never provided for by the CDC.

While the CDC has yet to release its updated draft guideline on prescribing opioids for chronic pain, the Opioid Task Force has released its comments, expressing deep concerns about the proposed changes. (Image: iStock)

Opioid task force, advocates warn CDC guidance updates are insufficient

In view of updating the much contested CDC guideline and in response to the significant number of reports of misapplication of the guideline after its initial publication, an Opioid Working Group was established in December 2019 by the Council of scientific advisers to the National Center for Injury Prevention. and Oversight (which is responsible for advising the CDC on certain issues) to review a first draft of the updated guideline and to offer conclusions and comments.3 This working group, made up of 23 clinicians and subject matter experts in the fields of pain medicine, primary care, public health, pharmacy, emergency medicine and many more, has now had the opportunity to review the CDC’s proposed updates to the directive – and they are not happy.

While the CDC has yet to release the updated draft guideline to the public, the Opioid Task Force has released its comments, expressing deep concerns about the proposed updates.4 The 12-page document highlights many problematic areas, including the fact that much of the text in support of the proposed directive is unbalanced, lacks key studies and has a strong focus on the risks of opioids, while less attention is paid to the potential benefits of opioids. , or the risk of not taking opioids or treating the pain. Additionally, the working group notes concerns about the sense of exception that pervades the guideline as pain related to cancer, palliative care and sickle cell disease is exempt from the guideline as if these conditions were more “real” or “worthy” of treatment than other chronic painful conditions. However, at the heart of their observations, none of the provisions of the 2016 guideline that have been misunderstood and misapplied for the past five years have been changed enough to avoid future damage.5

Advocacy groups and trade associations, eagerly awaiting the release of the CDC’s draft guideline, are very concerned about the lack of substantive updates. To illustrate how little the CDC has updated the guideline, the US Pain Foundation has released a side-by-side comparison of the 12 recommendations that appear in the 2016 guideline and the 2021 draft. The American Medical Association (AMA) s ‘also expressed, urging the CDC to remove arbitrary thresholds, restore balance and support comprehensive and compassionate care when the guideline is revised.6

Misapplication of CDC’s Opioid Prescribing Directive: State Actions

North Dakota Workers’ Comp to Not Cover Opioid Treatment Over 90 EMS / Day

In an almost classic example of the exact kind of misapplication of the CDC guideline warned by advocacy groups, North Dakota recently passed House Bill 1139 (2021), legislation relating to opioid dosage and duration limits.7 Under the newly enacted policy, which applies to the North Dakota Workers’ Compensation System, opioid therapy will not be covered if it exceeds 90 milligram morphine equivalents (MMEs) of opioid drugs per day, or more of a seven-day supply of an opioid medication, as part of a single outpatient transaction during the initial 30-day period of opioid therapy.

While these provisions are broadly in line with the 2016 CDC recommendations for initiating treatment at the lowest possible dose and timely follow-up visits during the first weeks of treatment, the new law is not limited to not to care provided by primary care physicians, as was provided for by the CDC guideline. Additionally, while the CDC recommends that a provider avoid increasing a patient’s dose to ≥ 90 MME / day, the CDC has explicitly pointed out that “… policies that impose strict limits conflict with the focus of the directive on the individualized assessment of the benefits and risks of given opioids. the specific circumstances and unique needs of each patient.8

By codifying these provisions, North Dakota has openly challenged the intentions of the CDC. The new law is expected to come into force on July 1, 2022.

Learn more about reconcile federal opioid guidelines with state laws.

Other states, having already testified to the patient suffering that can arise when opioid guidelines are improperly implemented, are actively taking steps to ensure that each patient’s unique needs are considered in the course of the treatment. pain management. However, even these well-intentioned pieces of legislation often illustrate underlying misunderstandings associated with the CDC directive and potentially perpetuate misapplication.

Rhode Island exempts intractable chronic pain from CDC opioid prescribing guidelines

Rhode Island recently passed a law relating to “intractable chronic pain”, defining this pain as “excruciating; constant; incurable, and of such severity that it dominates practically every conscious moment; and / or produces mental and physical impairment.9 The law goes on to say that a practitioner acting in good faith “may prescribe, administer and dispense controlled substances regardless of the 2016 CDC guideline for prescribing opioids for chronic pain” when treating a patient with pain. chronic intractable pain, diagnosed with cancer, or who receives palliative or nursing home care. The new law specifically requires practitioners to take into account the individualized needs of patients.

While the goals of Rhode Island’s legislation may be laudable, the need for such legislation in the first place is a testament to the widespread misunderstanding of the CDC guideline. First, the guideline was never intended to apply to patients receiving active cancer treatment or palliative care, so an exemption should not have been required. Second, it is not clear why “chronic intractable pain” was exempted by Rhode Island, as it appears to be the exact type of pain contemplated by the CDC guideline (assuming it is treated in a primary care setting). . One might assume that this exemption is intended to ensure that these patients are able to receive opioid doses greater than 90 MME / day, if their circumstances so require; however, there are no hard limits in the CDC guideline, so this exemption should have been unnecessary. Either way, it appears that Rhode Island has acknowledged that securing these exemptions through legislative action was necessary in order to protect a practitioner’s ability to properly treat their patients, and the provisions are entered into force upon adoption of the bill in June 2021.

Colorado improves clinical training on opioid prescribing

Similarly, responding to the current phenomena of under-treatment of pain and the problems linked to the rapid stopping of opioids, Colorado adopted House Bill 1276 (2021), aimed at ensuring that people living with chronic pain can receive appropriate care. Unlike Rhode Island’s choice to grant exemptions from the guidelines for certain types of patients, Colorado’s new law aims to educate practitioners by updating their continuing education requirements for opioid prescribers.ten As a condition of renewal of licensure on or after October 1, 2022, practitioners should be educated on the potential harms of inappropriately limiting prescriptions to patients with chronic pain, which will ideally reduce the number of patients with chronic pain. pain patients harmed by practitioner misunderstandings related to dosage, duration, and tapered guidelines.

It should be noted that Colorado law goes well beyond opioids in its efforts to ensure appropriate treatment for people with pain, adopting general requirements for compulsory insurance coverage for non-pharmacological alternative treatments to patients. opioids. Beginning in 2023, state health insurance plans will be required to align cost-sharing amounts for non-pharmacological pain treatments in cases where an opioid may be prescribed, including for visits physiotherapy, occupational therapy, chiropractic and acupuncture. These new insurance mandates will make it easier for practitioners to follow the CDC’s recommendation to consider opioid alternatives before starting or continuing opioid treatment, as patients will be able to access these alternatives at a more affordable price.

CDC Opioid Prescribing Guideline Updates Expected In 2022: Will The Changes Be Enough?

Ahead of the release of the 2016 guideline, advocates alerted the CDC to concerns about potential misapplication and misunderstandings related to their guideline recommendations. At the time, the concerns were all abstract possibilities that had not materialized, and the CDC believed the misunderstandings could be alleviated through education and awareness campaigns. However, now armed with five years of anecdotes from patients and practitioners, along with the proliferation of laws and state rules that clearly apply and misinterpret the directive, advocates hope the CDC will make some important updates. to alleviate these problems in the future.

The CDC’s updated guidelines for prescribing opioids for chronic pain are not expected to be finalized until late 2022,11 long after a draft has been released for public review and comment, there is still plenty of time for the agency to make substantive changes to the directive. According to the Opioid Workgroup – the only stakeholder group to have yet cast their eyes on the current project – there is still a lot of work to be done.

Last update on: August 3, 2021

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