Centers for Disease Control and Prevention (CDC): 2016 Guideline for Prescribing Opioids for Chronic Pain

By Chester 'Trip' Buckenmaier III, MD    May 20, 2016

 

“We cannot solve our problems with the same thinking we used when we created them.”

—Albert Einstein

 


The Centers for Disease Control and Prevention (CDC) released a Draft Guideline for Prescribing Opioids for Chronic Pain in January 2016.  This document followed close on the heels of the Presidential Memorandum – Addressing Prescription Drug Abuse and Heroin Use in October 2015.[1] This effort is certainly timely: in 2013, drug overdose, usually opioids, was the leading cause of injury death, surpassing motor vehicle accidents.[2] Perhaps even more sobering for healthcare providers is the fact that the source for most of these opioids is the medical community; prescription opioid sales have increased 300% since 1999 although there has not been a corresponding decrease in the amount of pain reported by Americans.[3]

As the Director of the Defense and Veterans Center for Integrative Pain Management (DVCIPM.org) the Military Health System’s Center of Excellence for pain management, my colleagues and I have struggled with this issue for over a decade. Both as an Army medical officer and now a federal medicine provider, I have seen the consequences of our reliance on drugs and procedures in the treatment of pain even longer. This national health crisis deserves the attention it is now receiving.  I do, however, have some real concerns about the focus of the CDC’s proposed guidelines and the process by which these were developed.  Given the narrow focus on drug management in the Presidential Memorandum, it is perhaps understandable that the CDC guidelines almost exclusively focus on the symptom of opioid misuse and abuse rather than the root cause of the problem:  poorly managed chronic pain.  Interestingly, the American Society of Anesthesiologists (ASA) and ASRA have also expressed concerns in a combined comment letter to the CDC.[4]

The omission of pain management as a root cause of the opioid problem was surprising given the CDC’s mission and long-standing success in ensuring public health. This may reflect the mission outlined in the Presidential Memorandum and a panel focused on opioid misuse, rather than on the comprehensive well-being of the very large population of Americans suffering from acute and chronic pain and the all too frequent consequences, such as disability, mental health disorders including suicide, and deterioration in social and occupational functioning which accompanies long-standing pain.  Perhaps most concerning is the omission in the guidelines to any references on the requirement to increase provider pain management education—again, a reflection of the scant mention it receives in the Presidential Memorandum.  It is unlikely that we will ever overcome the epidemic of opioid overuse, abuse, and diversion without adequately addressing the pain management education and training needs of clinicians. In contrast, the Department of Defense (DoD) and Veterans Health Administration (VHA) have been focusing and investing on improvements in pain management education for primary care providers.  The DoD and VHA have been collaborating for a number of years under the auspices of the Joint Pain Education Project (JPEP)[5] to build a primary care curriculum for pain management that includes best opioid prescribing practices within the larger context of pain management.  Failure to address the larger issue of pain management in America while focusing on the symptoms of this issue—prescription opioid misuse, abuse, and diversion—will likely result in a host of new unintended issues.  In a recent conversation with a prominent pain specialist, this approach was likened to managing a cholera outbreak in the modern era by solely focusing on the treatment of cholera patients while never bothering to inspect the community well or water source.

A focus solely on prescribing opioids also potentially denies these drugs when they are indicated and effective. The ASA/ASRA comment document expressed concerns that the guidelines might inappropriately limit physician use of opioids in specific situations such as post-surgical pain and the possible inaccurate portrayal of the effectiveness of interventional pain procedures, a key non-pharmacologic approach to pain management.  We in the DVCIPM and our VA colleagues would have gone even further and pointed out the guidelines’ exclusion of complementary integrative medicine (CIM) techniques (acupuncture, massage, physical therapy, yoga, and biofeedback for example) that tend to represent little side-effect risk to the patient but can be extremely effective modalities for appropriately selected patients.  CDC Guideline (1) mentions non-pharmacological therapy and non-opioid therapy as preferred treatment options for chronic pain.  It seems this is a missed opportunity to highlight evidence-based non-pharmacologic therapies that should be components of a multimodal treatment approach to pain. 

CDC Guideline (5) established specific morphine equivalent limits for prescribers of opioids.  While I agree that prescribers should always seek the lowest effective dose when prescribing opioid medications, establishment of hard ceilings for opioids is inconsistent with variations in patient responses to these medications, due to genetic or neuroplastic differences, or situations in which the nature of the stimulus may warrant greater opioid levels (palliative care or trauma for example).  In light of the national attention placed on this guideline and real potential to misinterpret the dosage recommendations as absolute thresholds, this guideline should be reconsidered with the focus on prescribing the lowest, effective opioid dose based on patient outcomes without establishing artificial limits.  This issue was also similarly recognized by the ASA/ASRA comments.

To echo the quote above from Albert Einstein, the achievement of full access to the complete spectrum of pain treatments will require a fundamental restructuring of public and private reimbursement for pain services. CDC Guidelines (7 – 10) assume an already established and coordinated system for managing acute and chronic pain that is not the current reality in most healthcare systems.  Significant adjustment to reimbursement for pain management services will be required to establish this pain care infrastructure in both primary and specialty care. 

Lastly, validated and coordinated patient-reported pain-related outcomes data is essential to justify and establish the efficacy of the non-opioid treatment options called for by the guidelines. Multiple national level documents dealing with the health crisis of chronic pain (DoD Pain Management Task Force, Institute of Medicine Report: Relieving Pain in America, National Pain Strategy) have collectively called for large, standardized pain patient data repositories.  One expression of this is the DoD’s Pain Assessment Screening Tool and Outcomes Registry (PASTOR) which can be reviewed at the DVCIPM.org portal.[6]

These guidelines are an essential first step but the broader mission of dealing with the pain problem in this country is just beginning with the recently released National Pain Strategy.[7]   We enthusiastically support the CDC’s effort to address the opioid problem in America.  It is our hope that the CDC will view the comments and concerns provided here and in the ASA/ASRA comment letter not as an attack, but as an opportunity to expand this effort to include the pain management community in resolving the larger issue of poorly managed pain that is driving much of the opioid problem.  ASRA has and should continue to play a leading role in this effort. 

References

  1. The White House – President Barack Obama. Presidential Memorandum –
    Addressing Prescription Drug Abuse and Heroin Use. 2015. Available at:
    https://www.whitehouse.gov/the-press-office/2015/10/21/presidentialmemorandum-
    addressing-prescription-drug-abuse-and-heroin. Accessed April
    7, 2016.
  2. Centers for Disease Control and Prevention (CDC). Web-based Injury Statistics
    Query and Reporting System (WISQARS) [online]. 2014. Available at: http://www.
    cdc.gov/injury/wisqars/fatal.html. Accessed April 7, 2016.
  3. CDC. Injury Prevention & Control: Prescription Drug Overdose [online]. 2016.
    Available at: http://www.cdc.gov/drugoverdose/prescribing/guideline.html.
    Accessed April 7, 2016.
  4. American Society of Regional Anesthesia and Pain Medicine comment letter
    Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids
    for Chronic Pain [online]. 2016. Available at: https://www.asra.com/content/
    documents/2016-1-6-_asa-asra_comments_cdc_guideline_final.pdf. Accessed
    April 7, 2016.
  5. Defense and Veterans Center for Integrative Pain Management (DVCIPM)
    [online]. 2016. Available at: http://www.dvcipm.org/clinical-resources/jointpain-
    education-project-jpep. Accessed April 7, 2016.
  6. DVCIPM [online]. 2016. Available at: http://www.dvcipm.org/clinical-resources/
    pain-assessment-screening-tool-and-outcomes-registry-pastor. Accessed April
    7, 2016.
  7. The Interagency Pain Research Coordinating Committee. 2015. Available at:
    http://iprcc.nih.gov/National_Pain_Strategy/NPS_Main.htm. Accessed April 7,
    2016.

Chester 'Trip' Buckenmaier III, MD, COL (ret), MC, USA, is the program director of the Defense and Veterans Center for Integrative Pain Management (DVCIPM.org) and a professor of Anesthesiology in the department of Military Emergency Medicine at the Uniformed Services University, USU '92

Copyright Protection: The author is an employee of the US Government. This work was prepared as part of official duties. Title 17 United States Code (USC) 105 provides that “Copyright protection under this title is not available for any work of the United States Government.” Title 17 USC 101 defines a US Government work as a work prepared by a military service member or employee of the US Government as part of that person’s official duties.

Disclaimer: The views expressed in this publication are those of the author, and do not necessarily reflect the official policy of the Department of the Army, the Department of Defense, or the United States Government.

Note: This article originally appeared in the ASRA News, Volume 16, Issue 2, pp. 8-9 (May 2016).

 


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