Hard thresholds dropped in new opioid guidance
Nuanced approach taken for pain patients
New guidance on prescribing opioids that was unveiled Thursday by the Centers for Disease Control and Prevention avoids the strict limits found in a 2016 version that accelerated a nationwide drop in pain pill prescriptions but led to backlash from chronic pain patients.
The 229-page document advises doctors to limit new opioid prescriptions and discuss alternative therapies with patients. But the new guidance largely avoids figures on dosage and length of prescription and warns against abruptly or rapidly discontinuing pain pills for some chronic pain patients.
“We’ve built in flexibility so that there’s not a one-size-fits-all approach,” said Christopher Jones, acting director of the CDC’S National Center for Injury Prevention and Control.
The document includes a dozen recommendations on how and when to manage pain patients, including non-pain-pill therapies, for people in non-hospital settings. Just as importantly, it does not include the “hard thresholds” from the 2016 version that “were essentially taken out of context beyond (their) intent and applied as rigid laws, regulations and policies,” Jones said.
The new guidance, available for the public to review and comment on over the next 60 days, is for doctors and non-physician prescribers who treat three categories of patients: adults with acute pain lasting less than one
month; “subacute” pain for one to three months; and chronic pain for three months or longer. It does not apply to sickle cell disease, cancer, palliative or end-of-life care.
For patients who have not taken opioids before, doctors should prescribe the lowest dosage. For chronic-pain patients, prescribers should be cautious about recommending opioids and gauge the risks and benefits, the guidance says.
Doctors and other clinicians should recommend pain pills for chronic pain patients only if expected benefits and ability to do everyday tasks outweigh known risks, which can include addiction, overdose, heart trouble, broken bones or falls.
Doctors also should discuss with patients the risks and benefits and should
consider how opioid prescriptions will be discontinued.
For patients already on higher dosages, clinicians should rely on other therapies and try to gradually lower dosages or discontinue opioids. However, unless there’s a life-threatening issue such as signs of overdose, doctors should not abruptly discontinue or rapidly reduce opioid dosages, the guidelines say.
“They are trying to thread a needle here,” said Dr. Joshua Sharfstein, a Johns Hopkins Bloomberg School of Public Health vice dean for public health practice and community engagement. “They’re trying to balance, on the one hand, the importance of clear guidance to clinicians and, on the other, the danger it could turn into a rigid policy that undermines patient care.”