The CDC released its 2022 Clinical Practice Guideline for Prescribing Opioids. While it remains mostly consistent in its approach towards opioids for the treatment of pain, it includes admissions of prior mistakes and misinterpretations, which speaks more loudly than any of the proposed revisions, slight as they may be.
The CDC begins by justifying its approach to the 2016 prescribing guidelines. But to their credit, the authors repeatedly chastise those who misapply or willfully misinterpret the guidelines for non-clinical – see legal – ends.
The authors were particularly keen to note the harmful effects of abrupt discontinuations and rapid tapering with no clinical justification. They made clear references to the scope and to the intended clinical audience of the guidelines – patients, physicians, and disease states. It was well-researched, well articulated, and succinct.
The heart of the report comes when the authors issue twelve recommendations and provide contextualized guidance on implementing those recommendations. It was the most expansive part and clearly the point of emphasis. The authors referenced multiple studies that highlight the risk-benefits of opioids as medication and should be commended for taking a deliberate, nuanced approach to opioid prescribing.
It is a start, no doubt. And to the CDC’s credit, it acknowledges many of the shortcomings in its previous approach. And for that, we must be grateful. But they continue to tout many of the same statements that were manipulated by law enforcement and policy makers in recent years.
They insist, repeatedly, that the guidelines are merely optional, not to be taken literally, or the primary means of decision-making. But that is precisely how they were taken since 2016.
They wax poetic about the benefits of shared clinical decision-making, drawing clever comparisons between informed consent and informed discussion, alluding to the value of patient trust. But they leave the discussion vague to the point of being incomplete. And in the past, law enforcement has filled that void with draconian restrictions on opioid medications, affecting millions of patients.
Yes, patient abandonment is an atrocity. The authors mention it ten times.
Yes, we must never abruptly discontinue or rapidly taper prescription opioids without just clinical cause. The authors mention it twenty-one times.
But what they do not mention is more important. They fail to mention how the risk-benefit assessments cited apply to individual patients.
Like a figurative atom, we focus on the nucleus while ignoring the orbiting electrons. Yet the behavior of electrons determines the characteristics of an atom. Similarly, what are left out of the revisions are the things that will have the greatest impact on patient care.
Instead of offering a clearly delineated approach to applying the guidelines to individual patients, they lace the report with vague, jargon-filled suggestions that provide no concrete means of implementation.
“As clinicians may work within team-based care, the recommendations refer to and promote integrated pain management and collaborative working relationships with, for example, behavioral health specialists, such as social workers or psychologists, and pharmacists.”
Obviously the authors are struggling to balance clinical data with individualized patient decision-making. They acknowledge as much in the conclusion when they discuss areas in need of additional research.
They offer poorly defined suggestions, attempting to contextualize advice for specific patients while acknowledging the limitations in those suggestions. It comes across as awkward at best. It demonstrates clear limitations in the authors’ ability to find coherent solutions to opioid prescribing practices without traversing into the realm of unintended consequences. And when they come to that point, they hedge with generalities that reiterate obvious truths.
“The clinical evidence reviews found no instrument with high accuracy for predicting opioid related harms such as overdose or opioid use disorder (Chou et al., April 2020). It can be very challenging for clinicians to predict whether benefits of opioids for chronic pain will outweigh risks of ongoing treatment for individual patients.”
The authors miss a valuable opportunity by not delving further into how the guidelines apply to individual patients. If they did, then they would find that many of the solutions to opioid prescribing come from addressing implicit biases in clinical decision-making.
Throughout the report, the authors make limited, passing references to implicit biases in prescribing patterns, referencing the plight of African Americans relative to other ethnicities. But implicit biases in healthcare extend beyond the race of a patient. It is inherent in all clinical decisions made.
And it is where we will find real solutions to the opioid epidemic – where we will find the balance between clinical data and individual decisions.
Instead, the authors remain bent on contextualizing all aspects of opioid prescribing as risk-benefits without providing any further guidance as to how such decision should be made individually.
This is the crux of the problem with the 2016 guidelines, and failing to acknowledge implicit biases in opioid prescribing is tantamount to failing to acknowledge how the misinterpretations of the original guidelines have harmed so many.
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We encourage all our readers to review the report in full and provide critical commentary for the CDC to review.
To read the full report, select the link below:
CDC Clinical Practice Guideline for Prescribing Opioids–United States, 2022
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Observations of this article are well intended and in many areas well taken. However, I believe you may be a few degrees off target. I have read most of the 211 pages of this monster document, as very few of your readers will be able to (particularly patients who are themselves in pain). My reading is that the primary objective of the five writers was to deflect criticism of their anti-opioid biases and preexisting agenda in the 2016 predecessor, while continuing its intended mission of suppressing the use of opioid analgesics in the treatment of pain. The writing has deliberately been made far more complex and self-contradictory than it needed to be.
The writers chose to employ a very old bureaucratic device: when you can’t convince your audience by reason and evidence, you baffle them with BS. Likewise, the document illustrates a second well known device: garbage in, garbage out. Many of the sources referenced in the document were wrong in their research protocol details or in their interpretation of available data or both. This is particularly true of five major outcomes reviews headed up by Dr Roger Chou and published by the Agency for Healthcare Research and Quality. I also point out that none of the five writers has ever treated pain patients in community practice. They know this field only from a theoretical perspective, not from practical experience. Small wonder that the resulting document repeatedly throws around the concept of risk-versus-benefit analysis without explaining how analysis is to be done. The intention was to frighten doctors out of practice who KNOW the difficulty of justifying and documenting such decisions to survive the ongoing DEA/DoJ policy of persecution.
I write as a subject matter expert in public policy for regulation of prescription opioids and of clinicians who employ them. I have 25 years experience as a non-physician healthcare writer and patient advocate, with over 150 published papers, articles, and interviews and tens of thousands of person to person contacts in peer-to-peer patient and family support forums on social media. I hope to publish a major rebuttal of the entire CDC process and findings in March.
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