Are CDC Guidelines Too Liberal Around Prescribing Opioids?

Most will find the 2022 CDC opioid guidelines, also published in the New England Journal of Medicine, similar to the CDC guidelines of 2016. But a new comment troubles me and adds to my worry that the previous recommendations were too liberal. The recent version, in my opinion, more clearly condones initiation of opioids in those not already taking them. From page 26 (following come caveats about opioids):

This does not mean that patients should be required to sequentially fail nonpharmacologic and nonopioid pharmacologic therapy or be required to use any specific treatment before proceeding to opioid therapy.” (Italics are mine).

My increased concern stems from their addition of the italicized portion in the 2022 version.

Source: Wellcome Collection gallery/CC-BY-4.0

The 2022 statement augments the already lenient 2016 comment about newly starting opioids. This now even more explicitly advises that clinicians do not need to try nonopioid treatments of any type before beginning opioids—that doctors can implement opioids as first-line therapy without even so much as first trying aspirin.

There is, however, the issue of political context. The CDC experienced considerable fallout from the 2016 recommendations: through no fault of their own, droves of clinicians misinterpreted the guidelines and began rapidly tapering or abruptly discontinuing opioids in patients, sometimes abandoning them altogether. Widespread psychological and physical harm ensued.

This led the authors of the 2016 guidelines and others to clarify that patients already taking opioids should not have them abruptly reduced or discontinued. They emphasized that any reductions should occur only in careful negotiation with the patient. And that these often fragile patients require careful attention to addiction to opioids (and, frequently, other licit and illicit substances), physical and psychological dependence on opioids, and potential misuse, such as selling them. Further, many have significant depression and anxiety disorders needing treatment.^1,2

In fairness to the authors, both the 2016 and 2022 versions explain at great lengths that prescription opioids for chronic pain lack any proven value or research support, reminding readers that opioids have caused horrendous adverse consequences; for example, over 200,000 deaths at the hands of prescription-writing clinicians. The authors also highlighted that clinicians should not use opioids as first-line treatment. The guidelines’ much greater emphasis on the avoid-opioid side of the story speaks to the message I suspect, absent political pressure, the authors would like to convey: do not initiate opioids in patients not previously taking them.

Source: Matthias Süßen: Poppy field in Schönberg, northern Germany./CC-BY-SA-4.0

So, what’s my issue with one sentence? Primary care clinicians prescribe most opioids, but they lack even the rudiments of training in mental health, much less in chronic pain and using opioids, as I extensively review in a prior post.

Unhappily, many of these same clinicians initiated opioids in the patients who suffered the above consequences. We must break this well-trod path, not condone it. If used at all in opioid-naïve patients, I propose that only well-trained addiction, mental health, and pain specialists should start opioids in patients. While I understand the political pressures, the CDC should not even hint at the option for untrained clinicians to initiate opioids in patients.

So what should the clinician do? My group has developed evidence-based guidelines that I summarized in a previous post and presented to a greater extent in a new textbook. Following these guidelines is demonstrably more effective than starting opioids.

I recommend that the CDC either delete the entire sentence in the first paragraph above or qualify it as applying only to trained specialists.