Back in 2016, the Center for Disease Control and Prevention released a guideline for primary care physicians treating patients 18 and older on how to prescribe and use opioid medications in response to the growing opioid addiction rates in the United States.(1) The CDC said the purpose of the guideline was to help primary care physicians works with patients to provide safe and effective pain management.(2)
In the three years since the guideline were released, however, it has had a far greater impact than intended and greatly affected the chronic pain community, including many IC patients. In fact, the impact has been so substantial that the CDC released a statement in April about the misapplication of the guideline.(2)
“Some policies and practices that cite the guideline are inconsistent with, and go beyond, its recommendations” the CDC said.(2)
- The guidelines have been applied to patients for whom it was never intended. The original intent of the guideline was for patients 18 and older in a primary care setting.(2)
- The dosage recommendations in the guideline have been misapplied and resulted in rigid limits or suddenly cutting off opioid prescriptions.
- The guideline was only to apply for when physicians were first starting to prescribe opioids and was NOT meant to tell physicians to discontinue the use of opioids already prescribed at higher doses.(2)
- The guideline does NOT advocate for abruptly tapering or discontinuing opioids already prescribed, because doing so can have severe negative effects on patients.(2)
- The dosages in the guidelines are meant to apply to using opioids in the management of chronic pain patients and not in the treatment of opioid use disorder.(2)
While insurance companies and other agencies like Medicaid have been quick to implement the CDC guideline in their policies, the misinterpretation of the guideline is leaving chronic pain patients in a lurch.(3) “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations,” said Deborah Dowell, MD, in an article published in the New England Journal of Medicine.(3)
Clinicians should not dismiss patients from care
which can adversely affect patient safety,
could represent patient abandonment
and can result in missed opportunities to
provide potentially lifesaving information and treatment.
Dowell, who is one of the original authors of the guideline, went on to say opioid policies should allow physicians to make their own clinical decisions based on their individual patients and those patients’ needs. Unfortunately, as Dowell pointed out, some physicians are instead opting to refer or dismiss chronic pain patients, so they don’t have to deal with managing ongoing opioid prescriptions. Other physicians have universally stopped prescribing opioids even when the benefits outweigh the risks.(3)
“Such actions disregard messages emphasized in the guideline that clinicians should not dismiss patients from care, which can adversely affect patient safety, could represent patient abandonment and can result in missed opportunities to provide potentially lifesaving information and treatment,” Dowell wrote.(3)
The 2016 CDC guideline that covered reducing the use of opioids also suggested alternative pain treatments in place of opioids as a first-line treatment. However, Dowell pointed out that these options aren’t well covered by insurance.(3)
“Appropriate implementation of the guideline included maximizing use of physical, psychological and multimodal pain treatments,” Dowell wrote. “However, these therapies have not been used, available or reimbursed sufficiently.”(3) As a result of these misinterpretations and coverage issues, the CDC has realized it needs to evaluate both the intended and unintended impact of the guideline.(3)
The CDC isn’t alone in recognizing that its guideline has had a negative impact. A study released at the beginning of April in “Pain Medicine” reported the results a multidisciplinary expert panel found on the challenges of implementing the CDC opioid guideline.(4)
While the panel supported the CDC guideline overall, it also found that the guideline had not been implemented as well as it was intended. Many physicians were disregarding the important role patients need to play in tapering opioid treatment. Additionally, and perhaps most concerning for chronic pain patients, the guideline has been misapplied by many policy-making and regulatory bodies without flexibility. The result is patients have trouble getting needed opioids or at least not having an abrupt cut-off of pain medication.(4)
The use of opioids in treating IC has also gotten some attention. At the annual American Urological Association meeting in May, researchers from Virginia presented their study looking at how often opioids are prescribed for IC patients. They found that 26% of IC patients had opioids prescribed within the first 30 days of being diagnosed with IC, in spite of opioids not being in the first line of treatment for IC.(5)
However, leading IC researchers, such as Dr. Philip Hanno and Dr. Christopher Payne, criticized the study by pointing out that most opioid prescriptions for IC patients come through emergency room visits and only 3% of the IC patients studied had an ongoing prescription for an opioid, which is a surprisingly low number. In short, it means that IC patients do sometimes need opioids for pain, but they are certainly not being overprescribed by urologists.
IC patients do sometimes need opioids for pain,
but they are certainly not being overprescribed by urologists.
The CDC is recognizing the problems that have come for chronic pain patients as a result of its 2016 opioid use guideline. The best solution being offered right now is for physicians to examine whether they are misinterpreting the guidelines. However, that doesn’t necessarily help IC patients who are struggling to get prescriptions. It does at least mean the situation is finally being recognized and hopefully some change will be on the way to both keep the opioid addiction rate from growing but also keep chronic pain patients from living in utter misery.
- Dowell D, et. al. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMRW. March 18, 2016 Volume 65, No. 1.
- Centers for Disease Control and Prevention. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain. April 24, 2019.
- Dowell D, et. al. No Shortcuts to Safer Opioid Prescribing. N Engl J Med. June 13, 2019 No. 380.
- Kroenke K, et. al. Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report. Pain Med. April 1, 2019 Volume 20, No. 4.
- Clements M, et. al. MP47-08 Opioid Prescription Use in Patients with Interstitial Cystitis. AUA Moderated Poster Session. May 5, 2019.