Opioids are often prescribed to help treat chronic pain.  In 2016 the CDC introduced the CDC Guideline for Prescribing Opioids for Chronic Pain. The 2016 guideline provided recommendations for primary care clinicians who were prescribing opioids for chronic pain, not including active cancer patient’s treatment, palliative care, or end of life care. The CDC guideline was based on the most recent scientific evidence, expert opinion, stakeholder, and public input at that time in 2016. It was estimated that approximately 20% of patients presenting to physician offices with noncancer pain symptoms or pain-related diagnosis for both acute and chronic pain were receiving an opioid prescription at that time. Studies showed that in 2012, health care providers wrote 259 million prescriptions for opioid pain medications.  That would be enough pain medication for every adult to have a bottle of opioid pain medication at the time.

The prescribing of opioid pain medication came with serious risks, including opioid use disorder and overdose. From 1999 to 2014 more than 165,000 individuals died from overdosing on opioids in the United States.  Some primary care clinicians had reported having concerns about opioid pain medication misuse, patient addiction, and lack of training in this area. The 2016 CDC guideline addresses when to initiate or continue the use of opioids for chronic pain, opioid selection, dosage, duration, follow-up, and discontinuation, assessing risks, and addressing harms of opioid use. The guideline was intended to improve communication between clinicians and patients about the risks and benefits associated with treatment options.

There was a great concern about the “allowable” prescribed daily dosage of opioid medications and overlapping opioid and benzodiazepine prescriptions because of the involved risks to patients. The CDC recommended the following steps for chronic pain providers: to assess risks to patient safety by conducting a physical examination, mental health screening, prescription drug monitoring program, urine screening, setting goals for improvements in pain and function, utilize non-opioid therapies and optimize them when possible, discuss risks and benefits with patients, and establishing criteria for discontinuing opioid therapy.

The CDC recommended that clinicians prescribe instant release opioid medications instead of extended -release opioids, prescribing the lowest effective dose below 50 MME daily, and reevaluating benefits and harms with patients within the first four weeks of prescribing opioid therapy. An MME is a Morphine milligram equivalent of an opioid dosage’s equivalency to Morphine. The MME is calculated by determining the total daily amount of each opioid the patient takes, converting each opioid to MMEs by multiplying the daily dosage for each opioid by its conversion factor, and then adding the opioid MMEs together.  Any use of opioid medication that exceeds 50 MME per day is considered to increase the risk for opioid related harms. An example would be a 4MG Hydromorphone pill taken three times daily with a conversion rate of 4 would have an MME of 4x4x3 = 48MME, which would be considered safe.

Now, there is a monumental problem that the implementation of the CDC “recommended” guideline has caused over the past five years. Thousands and thousands of long-term chronic pain patients have been cut off, weened off, or given alternative therapies for opioid therapy which does not help their chronic pain. These patients have been suffering and many have committed suicide because they could not get relief for chronic pain. The American Medical Association has been urging the Centers for Disease Control and Prevention to make significant revisions to its 2016 guideline for prescribing opioids for chronic pain to protect patients with chronic pain from ongoing unintentional consequences and misapplication of the guidance. The AMA has called for the CDC to remove arbitrary limits and other restrictions on opioid prescribing given the lack of evidence that these limits have improved outcomes for patients suffering chronic pain. Hard thresholds should never be used.  The stigma caused by the CDC has resulted in in legitimate chronic pain patients being denied proper pain management and care. James L. Madara, MD, Executive Vice President and CEO of the AMA sent a letter to the Chief Medical officer at the CMC, stating that the nation no longer has a prescription opioid-driven epidemic; however, we are now facing an unprecedented, multi-factorial and much more dangerous overdose and drug epidemic driven by heroin and illicitly manufactured fentanyl analogs, and stimulants.  We can no longer afford to view increasing drug-related mortality through a prescription opioid-myopic lens. Madara further comments on the need for CDC guideline revisions where the CDC works with physicians, and patients to ensure proper care for patients and fairness for the clinicians who care for them. The AMA task force affirms that some patients with acute and chronic pain can benefit from taking prescription opioid analgesics at higher doses than the CDC guideline recommends. The CDC guideline has harmed many patients, so much so that in 2019 the CDC authors and HHS issued long-overdue clarifications that states should not use CDC guidelines to implement an arbitrary threshold. The CDC guideline has been misapplied as a hard policy threshold by states, health plans, pharmacy chains, and PBMs.

In a statement by the CDC, they warn against misapplication of the 2016 guidelines. The recommendation does not suggest discontinuation of opioids already prescribed at higher dosages, or abrupt tapering or suddenly discontinuing opioids. The authors of the CDC guidelines recently stated that doctors and others in the health care system had wrongly implemented their recommendations and cut off patients who should have received pain medication.

The FDA has received numerous reports of serious harm, including serious withdrawal symptoms, uncontrolled pain, and suicide, in patients who depend on opioid pain medication, when these medications are reduced or suddenly discontinued.  Some patients have had to turn to illicit opioids, such as heroin to deal with their chronic pain. The AMA has found no medical standing for the CDC guideline and both the AMA and FDA has also acknowledged the harm done to pain patients. Addiction rates continue to rise even though very few opioid prescriptions are being written in 2021. For the past two years, the CDC has been in the process of updating its controversial opioid prescribing guideline, which has been widely blamed for patient suffering, abandonment, and suicides since its 2016 release. The new and improved version of the guideline should be released and adopted in 2021. Critics called the 2016 guideline a failed health experiment that has done more harm than good.

No one should have to live or die in pain! Those who are suffering with long-term chronic pain cannot last very long in chronic pain. We all must hope that the CDC does its job and that federal agencies will understand and adopt the new guideline that allows proper pain management with the needed dosage of opioid medications for those who truly need opioid therapy. The war on addiction is valid; however, the wrong approach was taken and can now be changed to fight the real war on heroin and analog drugs. Intentions were good; however, countless thousands have been harmed and continue to be harmed because they cannot get proper pain management with the use of opioid therapy which is the only therapy that works for some chronic pain patients. Drastic change is needed immediately.