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The authors of the CDC's 2016 guideline for opioid prescription for the treatment of chronic pain sought to clarify the guideline Wednesday, urging clinicians not to follow through on its recommendations.
Some policies and practices regarding opioids and chronic pain patients have been poorly implemented and do not reflect the 2016 recommendations, said guideline authors Deborah Dowell, MD, MPH, and Tamara Haegerich, PhD, both from the Atlanta CDC, and Roger Chou, from Oregon. University of Health and Science in Portland.
"Unfortunately, some policies and practices allegedly derived from the Directive have in fact been inconsistent with its recommendations and often go beyond them," they wrote in a statement. New England Journal of Medicine comment.
The inconsistencies – highlighted in a consensus report from the American Academy of Pain Medicine's Foundation (AAPM) – inflexibly include the application of dose thresholds and duration of opioids, as well as the promotion of strict limits and a gradual reduction in the number of opioids, they noted.
"The panel also noted the risk of misapplying recommendations to non-guideline populations," wrote Dowell and his colleagues. "Such actions are likely to harm patients."
In the commentary, the authors of the guidelines reviewed specific actions that may be harmful to patients, including:
Force the strict limits of opioid doses
The directive states that "clinicians should … avoid increasing The authors stated: "This statement does not address or suggest abandoning opioids already prescribed at higher doses, but does not suggest discontinuing opioids already prescribed at higher doses." it has been used to justify the sudden cessation of prescription or coverage of opioids ".
"The CDC based its recommendation on evidence of the adverse effects of opioids on the dose and on the lack of evidence that higher doses confer long-term benefits for pain relief," they added. . "However, we know little about the pros and cons of reducing high doses of opioids in patients who physically depend on them."
Opioids suddenly decrease or stop abruptly
Patients with chronic pain who are able to gradually reduce their opioid use may have a lower risk of overdose, but others may find it more difficult and cope with withdrawal symptoms, a increased pain or an unrecognized opioid consumption disorder "and if their dosage is lowered search for other sources of opioids or have adverse psychological and physical consequences," wrote Dowell and colleagues.
"The guidelines provide guidance for patients who are already taking opioid doses of 90 MME or more a day in the long-term, especially on the need to gradually reduce the dose, on the importance of diabetes." empathically examine the risks associated with the persistence of high-dose opioids, working with patients who agree to gradually reduce their dose, maximizing non-opioid treatment and decreasing slowly enough to minimize withdrawal symptoms " they continued. The guidelines do not support the abrupt cessation of opioid use, they added.
Applying recommendations to patients outside the guideline
The guidelines do not apply to patients in active cancer treatment or in acute attacks of sickle cell disease or postoperative pain, the authors said. Similarly, the dose limits recommended in the guideline do not apply to the use of drug-assisted treatment in patients with opioid use disorder.
Acknowledging that the recommendation has been misapplied or over-interpreted is an important first step, noted Kurt Kroenke, MD, of the Indiana School of Medicine in Indianapolis, first author of the AAPM Foundation consensus group report.
"However, the restrictive and overly restrictive prescribing policies created by legislatures and payers that have caused unintentional harm to the subgroup of opioid-treated pain patients will take longer to come back," he said. Kroenke MedPage today. "In addition, it will be more difficult to reverse the burdens, fears and stigma associated with the proper opioid prescription instilled to many clinicians."
While the AAPM consensus panel endorsed many parts of the 2016 guideline, "the best plans designed for mice and men may have failed," said Charles Argoff, MD, president of the AAPM consensus panel. the AAPM Foundation, in an interview with MedPage today.
"What's missing in this discussion is the real recognition of lost lives, not because of harm done to opioids, but because of the cessation of prescription opioids," Argoff added.
Dowell and colleagues noted that the CDC is evaluating the effects of the recommendation and will update their recommendations as new evidence becomes available. The agency is funding systematic reviews of the effectiveness of opioids and other acute and chronic pain treatments to identify research priorities and determine when gaps in evidence are being corrected. "Until then, we encourage the implementation of recommendations that are in line with the directive," they wrote.
1969-12-31T19: 00: 00-0500
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