At 1:00pm ET today, the CDC released its much debated Guideline for Prescribing Opioids for Chronic Pain.
PAINS was pleased to participate in the announcement call with CDC staff and others advocating for improved care for those living with chronic pain and those living with substance abuse disorders and addiction to opioids. PAINS welcomes evidence that CDC listened to the input from PAINS and other chronic pain advocates. Although the guidelines have been “softened” and somewhat revised, PAINS continues to have concerns about the lack of evidence base and the potential unintended harms to chronic pain sufferers that may occur.
PAINS Director, Myra Christopher, voiced those concerns during the conference call. Specific concerns she raised included:
- Distinguishing between cancer pain non-cancer pain.
Opioids delivered in the context of cancer, palliative and end-of-life care appear to be exempt from the guidelines. We pointed out that there is no evidence base for this distinction. Furthermore, as palliative care strives to move “upstream,” implementing the guidelines will be very complicated.
- Imposing dosage “limits” to chronic pain management.
Recommendation 5 recommends dosage limits when initiating and/or increasing opioid therapy. The recommendation states that, when prescribing more than 90 MME per day, clinicians should “carefully justify their decision.” Our concern is that this will lead to additional burden for documenting prescribing decisions and potentially result in a standard of care by which clinical decisions could be judged.
- Third party payers possibly using the guidelines for making decisions about prescription coverage.
PAINS is pleased to see that the revised version of Recommendation 1 encourages combining opioids (when they are used) with non-pharmacologic therapy and non-opioid pharmacologic therapy as appropriate. PAINS was created in 2011 to advance recommendations set forth in the Institute of Medicine report, Relieving Pain in America, which called for comprehensive chronic pain treatment, including complementary therapies and non-pharmacological approaches. The report stated that:
Pain results from a combination of biological, psychological and social factors and often requires comprehensive approaches to prevention and management.”
In the introduction of Relieving Pain, authors listed barriers to appropriate pain care. The first barrier stated was that “well-validated evidence-based guidelines on assessment and treatment have yet to be developed for some pain conditions, or existing guidelines are not followed.” (IOM, pg. 46).
PAINS is not sure that we yet have the guidelines called for in the IOM report or the forthcoming National Pain Strategy Draft; however, we are committed to work with CDC and others to reduce addiction and unintended deaths associated with opioids AND not unintendedly harm those who struggle to live with chronic pain or those who care for them.