AAFP Offers Mixed Comments on CDC's Opioid Prescribing Guidance

Academy Suggests More Research Is Needed to Better Support Recommendations

January 20, 2016 02:01 pm Chris Crawford

The AAFP recently offered its comments(www.regulations.gov) on the CDC's draft 2016 Guideline for Prescribing Opioids for Chronic Pain,(www.regulations.gov) which is intended for use by primary care health professionals who are treating patients with chronic pain (i.e., pain lasting longer than three months or past the time of normal tissue healing) in outpatient settings.

[Pills spilled out on table on top of Rx pad]

In a Jan. 13 letter(3 page PDF) to CDC Director Thomas Frieden, M.D., M.P.H., AAFP Health of the Public and Science Division Director Bellinda Schoof, M.H.A., and Medical Director Jennifer Frost, M.D., outlined the Academy's review of the guideline, which presents 12 recommendations for initiating or continuing opioid therapy for chronic pain, including drug selection, dosage, duration of treatment and followup, as well as risk assessment and addressing possible harms of opioid use.

To support the guideline's development, the Academy sent Robert Rich, M.D., chair of the AAFP Commission on Health of the Public and Science and the AAFP's representative on the AMA Task Force to Reduce Opioid Abuse, to participate on the CDC's Core Expert Group. After the proposed guideline was released, the Academy conducted a peer review of the document, examining its methodology and evidence base and assessing the recommendations made.

Ultimately, the AAFP agreed with some of those recommendations but expressed concerns about others stemming from the methodology used and a lack of supporting evidence.

Story highlights
  • On Jan. 13, the Academy sent comments to CDC Director Thomas Frieden, M.D., M.P.H., on the CDC's draft 2016 Guideline for Prescribing Opioids for Chronic Pain.
  • The guideline presents 12 recommendations for initiating or continuing opioid therapy for chronic pain, including drug selection, dosage, duration of treatment and followup, as well as risk assessment and addressing possible harms of opioid use.
  • The AAFP agreed with some of the guideline's recommendations but expressed concerns about others, questioning the CDC's methodology and the lack of supporting evidence.

According to Frost, family physicians may wish to consider a number of the recommendations for use in their practices. But, she noted, there just isn't a lot of high-quality clinical evidence available to support all 12.

"Literature review of available research has repeatedly revealed a paucity of research regarding best management options for acute and chronic pain, a lack of good-quality evidence pro or con regarding the use of opioids for pain and a lack of good-quality evidence for how to implement the use of opioids when a decision is made to prescribe opioids for pain control," Frost told AAFP News.

Recommendations as Good Practice

Frost said the pool of evidence supporting the side effects of opioid pain relievers is better than that bolstering recommendations for the overall use of opioid pain relievers for pain control.

Two of the guideline's recommendations reflect good practice, she said, but aren't supported by solid evidence. The first of these states that "treatment goals should be established before initiating opioid therapy, and treatment should be discontinued if there is no meaningful improvement in pain or function." The second notes that "before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy."

The Academy also supported a recommendation that physicians explore with patients the benefits and harms of starting opioid therapy for chronic pain or escalating the opioid dose beginning somewhere between the first week and one month of use and then again every three months or more frequently.

In addition, the AAFP agreed with a recommendation that physicians evaluate patients' risk factors for opioid-related harms and incorporate strategies to mitigate risk, including considering offering naloxone when there is a risk of opioid overdose.

Recommendations Requiring More Research

The AAFP found areas in which additional research would better support each of the recommendations. In some cases, recommendations were supported by little high-quality evidence or the evidence presented didn't directly apply to the primary care setting.

For example, one recommendation suggests that physicians should prescribe the lowest effective dose of opioids and use caution when increasing the dosage to 50 morphine milligram equivalents (MME) per day or more. The guideline also states that physicians should avoid increasing the dosage beyond 90 MME per day.

"These thresholds are based on evidence that opioid overdose risk increases in a dose-response manner; but the actual dose cutoffs chosen are based on expert opinion, not evidence," Frost said.

Similarly, another recommendation called for a duration of therapy of three days or less for treatment of most acute nontraumatic pain. However, this is based primarily on a review of literature obtained from studies in the ER setting, said Frost; there continues to be a paucity of literature regarding treatment of acute pain in the primary care setting.

Up Next in the Process

Although an AAFP representative participated on the team that developed the guideline, the Academy won't decide whether or not to endorse the document until the CDC reviews feedback collected on the draft version and releases its final guideline.

The AAFP team will then again put the guideline through a rigorous review process to determine whether it agrees with the final recommendations.

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