Revisions to CDC opioid guidelines and reflections from a pain specialist  

Last month, the CDC backed down on strict opioid guidelines amid backlash from providers and chronic pain patients. As a pain specialist, I’ve seen firsthand the drastic change in opioid prescribing since the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain was published.

Opioids have been routinely overprescribed since pain was considered a fifth vital sign in the late 1990s and early 2000s. Drug companies pressured providers to aggressively treat pain with opioids. But opioids do not come without risk, which include respiratory depression, altered mental status, confusion, constipation and more. More concerning, there are also risks of tolerance, dependence, addiction and overdose, and these contributed to the opioid epidemic. What we know now about opioids is significantly different than what we knew 20 years ago.

In 2016, the CDC provided 12 recommendations that were quickly adopted by the medical community and legislators as the gold standard. This added to the momentum in slowing down the opioid epidemic. In 2015, 52,404 drug overdose deaths occurred with 63.1% (33,091) involving opioids. By 2016, drug overdose deaths increased to 63,632 with 66.4% (42,249) involving opioids. This was a 27.6% increase in opioid related deaths in one year.

Soon after the 2016 guidelines, we saw a drastic decrease in opioid prescribing by physicians. However, providers were forced to use a one size-fits-all approach. Although these guidelines helped to curb the opioid epidemic, they were considered too restrictive, for example, limiting acute pain opioid prescriptions to three days or avoiding increasing opioid dosage above 90 morphine milligram equivalents (MME) for chronic pain.

In February 2022, CDC provided their first comprehensive revision to the guidelines since adoption in 2016. If these guidelines are accepted after the 60-day evaluation period, doctors will have more flexibility in prescribing opioids. The CDC would like physicians to use their best judgement. If an episode of acute pain or postsurgical pain requires a longer short-term course of opioids, then that would be considered acceptable. If a patient requires a higher than 90 MME, that would also be considered acceptable. If formally accepted, we will no longer see the one-size-fits-all approach.

Over the past several years, we have been able to assess, adapt and make changes to the guidelines to ultimately provide the best patient care as possible. The initial 2016 guidelines were much needed as they helped curb the overprescribing of opioids and provided a set of guidelines and structure to doctors. It is now time for a revision of the guidelines after collecting and analyzing data of how patients and doctors have responded to them.

Patients are often left with limited pain medications after surgery, accidents or burns, but in these instances, opioids are often a reasonable option. We should start with the lowest effective dose and use short-acting opioids instead of long-acting opioids. I am hopeful with the revised guidelines that we will find a happy medium in treating pain but not forgetting about the opioid epidemic that we worked so hard to contain.

By Dr. Krishna Shah, assistant professor, Interventional Pain Medicine, Department of Anesthesiology, Baylor College of Medicine