Page 32 - CASA Bulletin of Anesthiology 2021, Vol 8, No. 6 (1)

CASA Bulletin of Anesthesiology

Prescribing opioids for chronic, non-malignant pain: an update

since the CDC guidelines

Kenneth S Tseng, MD, MPH

Department of Anesthesiology, INOVA-Fairfax Hospital
Falls Church, VA, USA
Department of Anesthesiology, University of Virginia
Inova Campus, Falls Church, VA, USA

In 2016, the Centers for Disease Control (CDC) published
recommendations for prescribing chronic opioid therapy for
treatment of non-malignant pain. The focus of its publication
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were twelve guidelines intended to provide guidance for primary
care providers, who collectively prescribed the largest proportion
of opioids. Some of these guidelines were generalizations, such as
starting with non-opioid treatments, establishing treatment goals,
and discussing the risks and benefits with patients. However,
several of the guidelines set numeric thresholds for dose and
duration of therapy: most notably, recommendation number 5
stated “Clinicians... should carefully reassess evidence of individual benefits and risks when
increasing dosage to >50 morphine milligram equivalents (MME)/day, and should avoid
increasing dosage to >90 MME/day or carefully justify a decision to titrate dosage to >90
MME/day.” For many health care providers, this seemed like a watershed moment. More than
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thirty state legislatures passed laws setting strict limits on the number of opioids that could be
prescribed: Maine restricted opioid prescriptions to less than 100 MME/day, Nevada less than
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90 MME for initial prescriptions, and Rhode Island passed a bill restricting treatment of acute
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pain to 30 MME or less. Some physicians began tapering the daily usage of opioids to 90 MME
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for all their patients, and others refused to prescribe opioids altogether. For perioperative
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physicians, including anesthesiologists, this coincided with a push to offer opioid-free surgery.
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Unfortunately, many patients who had been on long-term opioid therapy reacted unfavorably
to these new changes, and a retraction within the medical field followed shortly afterwards. The
authors of the CDC guidelines published an editorial in The New England Journal of Medicine
(NEJM) in which they stated “some policies derived from [our] guideline have in fact been
inconsistent with, and often go beyond, its recommendations…” With regards to
recommendation #5 that clinicians avoid increasing doses above 90 MME, they wrote “this
statement does not address or suggest discontinuation of opioids already prescribed at higher
dosages, yet it has been used to justify abruptly stopping opioid prescriptions or coverage… An
unintended consequence of expecting clinicians to mitigate risks of high-dose opioids is that
rather than caring for patients receiving high doses, some clinicians may find it easier to refer or
dismiss patients from care. Clinicians might universally stop prescribing opioids, even in
situations in which the benefits might outweigh their risks.” Another letter signed by 300
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medical experts, including three former White House drug czars from the Obama, Clinton, and
Nixon administration, asked the CDC to clarify their guidelines to avoid the misapplication by
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