Opioid Epidemic

CDC Admits That Prescribing Guidelines for Opioids Have Not Been Used Correctly

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What are the CDC Guidelines?

The Centers for Disease Control and Prevention (CDC), in March of 2016, they released guidelines for the treatment of chronic pain by primary care physicians, in terms of the use of opioid medications in individuals over the age of 18. Those guidelines focused on: using non-opioid medications and treatments first, defining realistic treatment goals for pain and functioning with their patient, discussing the risk of opioid therapy prior to beginning treatment, start with immediate release opioids and at the lowest possible dose, evaluate the benefits and risks of opioid therapy every 3 months, review the individual’s risk for opioid use disorder and arrange treatment as needed, avoid concurrent benzodiazepine prescriptions, and conduct urine screenings. The CDC guidelines stated doctors should avoid increasing doses over 90mme (morphine milligram equivalent).

FDA Response to Sudden Withdrawal or Tapers of Opioid Medication

As an effect of these guidelines, on April 9, 2019, the U.S. Food and Drug Administration (FDA) issued a report concerning the seriousness of the sudden discontinuation of opioid pain medications in individuals who have been treated with opioids, some for extended periods of time. Withdrawal symptoms may be severe, and even life-threatening, if the dosage is suddenly stopped or rapidly lowered.

As a result the FDA is requiring changes in how opioids are prescribed including how to slowly, yet safely, decrease the dosage for those individuals who have been taking these medications for significant periods of time.

CDC Response to FDA & Doctors

The CDC has recently acknowledged its guidelines as being a reason for the epidemic of discontinued opioid prescriptions as well as the hasty tapering of opioids. On April 10, 2019, the CDC Director, Dr. Robert Redfield, wrote to physicians, who had asked for clarification of the CDC guidelines, that they are working to evaluate the impact of the guidelines and to clarify recommendations. The CDC also stated that their guidelines were not to address those individuals who were currently prescribed opioids by pain management specialist or for those who may be prescribed the medication due to cancer, sickle cell disease, or end of life care.

The CDC's response was published in The New England Journal of Medicine and comes three years after issuing the guidelines in 2016. The CDC states that their guidelines were misinterpreted and that they do not support abrupt tapering, tapering without consent, or sudden discontinuation of opioids. This can be too late for many individuals who have suffered the effects of the reduction of pain medications or having their pain medication totally removed.

This leaves many individuals with chronic pain wondering why it took the CDC so long to clarify their guidelines. There is still great controversy concerning this issue. Some are under the impression that the CDC guidelines were misapplied so greatly that it will be hard to correct. Physicians are also left confused as many were punished for treating individuals with chronic pain the way the CDC guidelines where to be used.

Common opioids include, but are not limited to, oxycodone, hydrocodone, codeine, fentanyl, morphine, and oxymorphone. While both the CDC and FDA agree that opioids can be dangerous, the FDA warns that physicians should never discontinue opioids abruptly for patients. Individuals should also never decide to suddenly stop taking their opioid pain medication “cold turkey” without speaking with their physician first.

How to Taper?

Tapering slowly off opioids is the safest way to reduce a dosage or come completely off the medication. However, what works for one individual may not work for another. Physicians must develop a plan that works for each individual. Physical withdrawals may occur even with a gradual decrease in opioids, physical withdrawal does not mean an individual is addicted to the medication. The dosage currently prescribed and the length of time an individual has been on it for treatment must be considered prior to starting a taper. The individual should also be consulted regarding the taper plan. The CDC recommends that a medication taper should start with 10% of the original dose every week to month, depending on the individual.