• New Opioid Prescribing Guideline Emphasizes Flexibility

    CDC Recommendations Address Initiation, Dosage, Duration, Risk, More

    November 28, 2022, 8:40 a.m. Michael Devitt — The AAFP is reviewing a new update of the CDC Clinical Practice Guideline for Prescribing Opioids for Pain that is intended to assist family physicians and other clinicians who prescribe opioids for adults with pain in outpatient settings.

    Older physician talking with patient

    The guideline “will hopefully lessen the concern many family physicians feel about overregulation of pain care by insurers and various regulatory boards, including the scrutiny of opioid prescribing,” said Robert “Chuck” Rich, M.D., medical director of Bladen Medical Associates in Elizabethtown, N.C., who also serves as the Academy’s representative to the AMA Substance Use and Pain Care Task Force, the American Academy of Addiction Psychiatry’s Providers Clinical Support System Steering Committee and the National Academy of Medicine’s Action Collaborative on Countering the U.S. Opioid Epidemic.

    “While these changes may take some time to occur, the new guidelines recognize that there is a place for holistic pain care encompassing multiple modalities including properly prescribed and monitored opioid therapy,” Rich added.

    The new publication updates and expands the CDC’s 2016 guideline, and gives recommendations for managing acute, subacute and chronic pain. It addresses dosing strategies, tapering and discontinuation, comparison with nonopioid therapies, and risk mitigation.

    The AAFP gave the previous version of the guideline an “affirmation of value” designation in April 2016, agreeing with some recommendations while expressing concerns about others due to inconsistent inclusion and exclusion criteria in the methodology and a lack of high-quality supporting evidence.

    Story Highlights

    The Academy issued a reaffirmation of value for the 2016 version in July 2021.

    Guideline Details

    The new 100-page document is intended to help clinicians and patients in the decision-making process, with detailed recommendations and guiding principles for

    • determining whether to initiate opioids for pain;
    • selecting opioids and determining appropriate dosages;
    • deciding the duration of initial opioid prescription and conducting follow-up; and
    • assessing risk and addressing potential harms.

    It aims to be flexible, accounting for each patient’s needs, expected health outcomes and well-being with a primary objective of ensuring that people “have equitable access to safe and effective pain management that improves their function and quality of life while illuminating and reducing risks associated with prescription opioids.”

    The guideline details some of the social, economic and policy factors that contribute to high rates of overdose deaths in rural and economically disadvantaged areas. For family physicians and others who prescribe opioids, this suggests that understanding how social determinants of health impact patient care and outcomes is an integral component of effective pain management.

    The guideline’s recommendations do not apply in cases of sickle cell disease, cancer, palliative care or end-of-life care. The guideline also clearly states that it is not designed to replace clinical judgment or individualized care, nor should it be considered a law, regulation or policy that dictates clinical practice or substitutes FDA-approved labeling.

    “The recommendations are voluntary and provide flexibility to clinicians and patients to support individualized, patient-centered care, the CDC explained in a media release. “They should not be used as an inflexible, one-size-fits-all policy or law or applied as a rigid standard of care or to replace clinical judgement about personalized treatment.”

    Family Physician Perspective

    Rich, who shared draft reviews with the AAFP and the NAM, noted several improvements in the update.

    “The updated CDC guideline better recognizes the role that properly prescribed opioid therapy can play in pain care, particularly for patients with chronic pain already on long-term opioid therapy,” he said.

    “The new guideline also better appreciates how social determinants of health have impacted the availability of nonopioid therapies for certain populations and calls for addressing the funding and provisions of those modalities, which should lessen the need for opioid therapy. Finally, the new guideline better appreciates the perspective of the patient in their pain care and calls for enhanced shared decision-making in that process.”

    Rich emphasized five key takeaways for family physicians treating pain:

    • Provide pain care while considering the risks and benefits of all available modalities.
    • Choose treatments with the patient’s input.
    • Maximize multimodal therapies, which may reduce the need for opioid therapy.
    • Do not abruptly stop or rapidly taper a patient’s existing long-term opioid therapy.
    • Thoroughly document the decision-making process for starting or continuing each patient’s opioid therapy.

    Social Determinants of Health

    The CDC said it’s important to understand how social determinants of health can affect patient outcomes and quality of care, noting that “social, economic, educational and neighborhood-level factors might create and exacerbate health inequities that certain persons experience throughout their lives.”

    To address these concerns, the agency is calling on clinicians, practices, health systems and payers to “attend to health inequities to protect patient safety; guard against unnecessary risks; and ensure access to appropriate, diversified, effective nonpharmacologic and pharmacologic pain management options that are person-centered, affordable, accessible, and well-coordinated.”

    Such an undertaking begins with “raising awareness and acknowledging the presence of these inequities, strengthening patient-clinician communication, leveraging community health workers, implementing multidisciplinary care teams, tracking and monitoring performance measures, and integrating quality improvement initiatives that support and invest in guideline-concordant care for all persons.”

    The CDC will share evidence with public and private payers to help make determinations about coverage for nonpharmacologic treatments, access to nonopioid pain medications and evidence-based treatments for opioid use disorder, support for patient counseling and coordination of care, and increased availability of multidisciplinary care.

    The agency also plans to develop resources related to the guideline, including fact sheets, public service announcements and a mobile app.

    AAFP’s Thorough Review Begins

    The AAFP gave the CDC advice as the agency worked on the updated guideline.

    Now the Academy has started a careful review of the final document, following the process for consideration of external organizations’ evidence-based clinical practice guidelines. It will take some time to complete.

    All external clinical practice guidelines that the AAFP considers for endorsement go through a structured review process by the Commission on Health of the Public and Science with approval by the Board.

    The Academy will inform members of its stance on the new opioid prescribing guideline once that work is finished.