ACP, AMA critique CDC guidelines on use of opioids for chronic pain

The ACP and AMA have commended the CDC for the development of the Draft Guideline for the Use of Opioids for Chronic Pain, according to letters from both organizations.

As detailed by the CDC, existing guidelines are not consistent in their recommendations and primary care providers would benefit from updated clinical practice guidelines.

Data cited by the CDC demonstrated that opioid use is increasing throughout the country: Sales in the United States have increased by 300% since 1999 despite no overall increases in pain reported.

The guidelines address the initiation or continuance of opioids for chronic pain; opioid selection, dose, duration, follow-up and discontinuation; and assessing and addressing the risks and harms of opioid use, according to the CDC. After review of the guidelines, the ACP and AMA addressed the strengths and recommended various revisions they feel are necessary before implementation.

"The guideline development effort is both timely and necessary to help effectively address the increasingly clear public health problem of inappropriate opioid use and its related adverse consequences," Wayne J. Riley, MD, MPH, MBA, MACP, president of the ACP, wrote in the organization's letter to the CDC. "The College particularly commends the CDC for focusing on primary care health care professionals, who serve as the first contact for most patients suffering from pain-related conditions, and who, according to a recent study, are the largest prescribers of schedule II opioid medications."

Commenting on the guidelines as a whole, Riley urged the CDC to stress that they did not serve as prescriptive standards and to place them in a broader context with other federal efforts. More specifically, the ACP recommended revisions that include increased flexibility in dosage adjustments that reflect physician judgement and more detailed approaches for primary care providers to diagnose the presence of opioid use disorder.

On behalf of the AMA, James L. Madara, MD, executive vice president and CEO of AMA, wrote in the organization's letter to the CDC that it supports many of the recommendations, but the guidelines would benefit from revisions and the inclusion of a more balanced advisory committee.

"We continue to have serious concerns that some [recommendations] either contain a degree of specificity not supported by the existing evidence or conflict with official FDA-approved product-labeling for opioid analgesic products," Madara wrote. "It seems incongruous that virtually all of the specific guidelines carry a graded recommendation that CDC believes should ‘apply to all patients with chronic pain and that ... most patients should receive the recommended course of action,’ given the limitations of the evidence, especially where CDC experts' opinions are the essential foundation for the recommendation."

Madara also stressed that the CDC seriously consider the role of patients who experience chronic pain, who "increasingly view themselves as collateral damage in efforts to restrict opioid prescribing decisions" and worry that their access may be restricted despite legitimate needs.

"The proposed guideline could be substantially improved by incorporating some fundamental acknowledgements that many patients experience persistent pain that is not well controlled, substantially impairs their quality of life and/or functional status, stigmatizes them, and could be managed with more compassionate patient care," he wrote.

The guidelines are still open for comments and there is no timetable for release. On its website, the CDC stated that "the agency is working for timely release of the guideline."

The ACP and AMA have commended the CDC for the development of the Draft Guideline for the Use of Opioids for Chronic Pain, according to letters from both organizations.

As detailed by the CDC, existing guidelines are not consistent in their recommendations and primary care providers would benefit from updated clinical practice guidelines.

Data cited by the CDC demonstrated that opioid use is increasing throughout the country: Sales in the United States have increased by 300% since 1999 despite no overall increases in pain reported.

The guidelines address the initiation or continuance of opioids for chronic pain; opioid selection, dose, duration, follow-up and discontinuation; and assessing and addressing the risks and harms of opioid use, according to the CDC. After review of the guidelines, the ACP and AMA addressed the strengths and recommended various revisions they feel are necessary before implementation.

"The guideline development effort is both timely and necessary to help effectively address the increasingly clear public health problem of inappropriate opioid use and its related adverse consequences," Wayne J. Riley, MD, MPH, MBA, MACP, president of the ACP, wrote in the organization's letter to the CDC. "The College particularly commends the CDC for focusing on primary care health care professionals, who serve as the first contact for most patients suffering from pain-related conditions, and who, according to a recent study, are the largest prescribers of schedule II opioid medications."

Commenting on the guidelines as a whole, Riley urged the CDC to stress that they did not serve as prescriptive standards and to place them in a broader context with other federal efforts. More specifically, the ACP recommended revisions that include increased flexibility in dosage adjustments that reflect physician judgement and more detailed approaches for primary care providers to diagnose the presence of opioid use disorder.

On behalf of the AMA, James L. Madara, MD, executive vice president and CEO of AMA, wrote in the organization's letter to the CDC that it supports many of the recommendations, but the guidelines would benefit from revisions and the inclusion of a more balanced advisory committee.

"We continue to have serious concerns that some [recommendations] either contain a degree of specificity not supported by the existing evidence or conflict with official FDA-approved product-labeling for opioid analgesic products," Madara wrote. "It seems incongruous that virtually all of the specific guidelines carry a graded recommendation that CDC believes should ‘apply to all patients with chronic pain and that ... most patients should receive the recommended course of action,’ given the limitations of the evidence, especially where CDC experts' opinions are the essential foundation for the recommendation."

Madara also stressed that the CDC seriously consider the role of patients who experience chronic pain, who "increasingly view themselves as collateral damage in efforts to restrict opioid prescribing decisions" and worry that their access may be restricted despite legitimate needs.

"The proposed guideline could be substantially improved by incorporating some fundamental acknowledgements that many patients experience persistent pain that is not well controlled, substantially impairs their quality of life and/or functional status, stigmatizes them, and could be managed with more compassionate patient care," he wrote.

The guidelines are still open for comments and there is no timetable for release. On its website, the CDC stated that "the agency is working for timely release of the guideline."