Some states and caregivers adopted tight rules based on the recommendations, first issued in 2016, resulting in patients having difficulty obtaining pain drugs or having them cut off abruptly.
“There’s not a one size fits all,” said Christopher Jones, acting director of the National Center for Injury Prevention and Control, part of the Centers for Disease Control and Prevention. “We’ve heard that quite clearly. When you have hard thresholds like 90 [morphine milligram equivalents] or a specific duration, it makes it too easy for policymakers or others to take that out of context and apply that as a rigid cap.”
Bobby Mukkamala, chairman of the American Medical Association Board of Trustees, issued a statement saying that “for nearly six years, the AMA has urged the CDC to reconsider its problematic guideline on opioid prescriptions that proved devastating for patients with pain. The CDC’s new draft guideline — if followed by policymakers, health insurance companies and pharmacy chains — provides a path to remove arbitrary prescribing thresholds, restore balance and support comprehensive, compassionate care.”
Andrew Kolodny, one of the fiercest critics of opioid manufacturers, said he believes some of the opposition was orchestrated by drug companies that saw the attempt to curb opioid prescribing — especially of high-dose pills — as a threat to their profit margins.
The advice on a numerical cap “was necessary and helpful, and the CDC should not have removed it,” said Kolodny, founder of the group Physicians for Responsible Opioid Prescribing and medical director for the Opioid Policy Research Collaborative at Brandeis University.
“Taking it out as well as other recommendations in the guidelines are not congruent with the evidence base that the guideline is relying on,” he said.
Like the landmark 2016 guidance, the new recommendations strongly urge care providers to first choose non-opioid alternatives for all kinds of pain, including over-the-counter drugs such as nonsteroidal anti-inflammatory drugs (NSAIDs), massage, acupuncture and physical therapy. They also offer expanded advice on treatment of acute pain (pain that lasts less than one month), based on research in recent years, Jones said.
Wednesday’s 229-page updated proposal comes almost six years after the CDC belatedly tried to curb the liberal use of opioid pills, a treatment approach that developed in an era when caregivers were pressured to treat pain aggressively and drug companies were downplaying the chances of addiction.
Doctors complained that they were dispensing large quantities of painkillers without the training on how to do so and that painkillers sometimes proved to be a gateway drug for the use of heroin and illegal street fentanyl. About 165,000 people died of overdoses of prescription painkillers between 1999 and 2016.
In regard to the long-term use of opioids, the 2016 recommendations found that “three days or less will often be sufficient; more than seven days will rarely be needed.”
Patients, some of whom had been taking opioids for years, rebelled. In 2019, more than 300 health-care experts, including three former U.S. drug czars, told the CDC its guidelines were harming patients. They said the advice had prompted some insurers to refuse reimbursement, led pharmacies to erect obstacles to obtaining drugs and created risks for doctors who wanted to give out more.
The new guidelines, published Thursday in the Federal Register, are not binding on prescribers and are not intended to apply to end-of-life pain care, or pain care for diseases such as cancer and sickle cell anemia. After a public comment period ends April 11, the CDC will decide whether to adopt them and whether to make changes to the proposal.