CDC Admits That Prescribing Guidelines for Opioids Were Widely Misinterpreted
What are prescription opioids?
Prescription opioids are pain medications used to treat moderate to severe pain. Opioids block pain signals by attaching to receptors in the nervous system. Common opioids include, but are not limited to, oxycodone, hydrocodone, codeine, fentanyl, morphine and oxymorphone. Both the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA) agree that opioids can be dangerous if not used as prescribed. However, the FDA warns that physicians should never abruptly discontinue an individual’s opioid treatment. Also, individuals should not attempt to stop taking their opioid pain medication without speaking with their physician first.
What are the CDC guidelines?
In March 2016, the CDC 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. The guidelines involved the following:
- Try non-opioid medications and treatments first.
- Define realistic treatment goals for pain and functioning with the individual.
- Discuss the risk of opioid therapy before 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.
- Conduct urine screenings.
- Avoid increasing doses over 90mme (morphine milligram equivalent).
FDA response to sudden withdrawal or abrupt tapering of opioid medications
On April 9, 2019, the FDA issued a report concerning the seriousness of sudden discontinuation of opioid pain medications in individuals who have been treated with opioids for extended periods. Opioid withdrawal symptoms are often 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 dosages for individuals who have been taking these medications for a significant time.
CDC response to FDA and health care providers
The CDC has recently acknowledged the 2016 guidelines were misinterpreted and may be part of the 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 a group of health care professionals (who had asked for clarification of the CDC guidelines) that the CDC was working to evaluate the impact of the guidelines and to clarify recommendations. The CDC also stated that their guidelines are not aimed at individuals who are currently prescribed opioids by pain management specialists or for those who are 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 the guidelines were issued 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. Unfortunately, the clarification came too late for many individuals with chronic pain conditions who dealt with the effects of a sudden reduction of their pain medication(s) or abrupt discontinuation of their opioid prescription(s).
Many individuals with chronic pain wonder why it took the CDC so long to clarify their guidelines. Great controversy still surrounds this issue. Some are under the impression that the CDC guidelines were misapplied so greatly that it will be very difficult to correct. Physicians are also left confused as many were punished for continuing to prescribe opioids for individuals with chronic pain after the release of the CDC guidelines.
How to safely taper
Slowly tapering 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. An individualized treatment plan works best. The current dosage and the amount 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 a 10% decrease of the original dose every week or month, depending on the individual. Physical withdrawals may occur even with a gradual decrease in opioids. It is important to note that physical withdrawal does not necessarily mean that addiction is an issue; addiction and physical dependence are two separate issues.