Page 35 - CASA Bulletin of Anesthiology 2021, Vol 8, No. 6 (1)

Vol. 8, No. 6, 2021

overdose events per 100 person-years in tapered periods vs 5.5 events per 100 person-years in
non-tapered periods.
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While most pain experts continue to acknowledge that long-term opioid use is not the
solution to chronic pain management, the focus has shifted away from eliminating opioids
altogether, but instead towards promoting other methods of analgesia that may be less risky. In
their 2019 NEJM editorial, the authors of the CDC guideline concluded by saying “appropriate
implementation of the guideline includes maximizing use of physical, psychological, and
multimodal pain treatments. However, these therapies have not been used, available, or
reimbursed sufficiently. The CDC has supported research to better define the evidence and
coverage gaps for nonopioid pain treatments and has articulated the need to improve insurance
coverage. Efforts to support more judicious opioid use will become more successful as effective
non opioid treatments are increasingly available and used.” Within perioperative medicine,
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anesthesiologists scaled back from the push for “opioid-free anesthesia” and re-framed the
administration of a balanced anesthetic as “opioid-sparing.”
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In 2016, the Department of Health and Human Services, in conjunction with the DOD and
the VA formed an Inter-Agency Task Force. The task force included pain experts both in and out
of government. Together, they reviewed scientific literature and heard about 9000 public
comments. In 2019, the task force published its recommendations, which focused on a
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biopsychosocial model of care with five prongs, placing equal weight on medications, restorative
therapies (such as physical/occupational therapy), interventional approaches, behavioral
approaches, and complementary/integrative health. Regarding opioid prescribing, the task force
pushed back against what it considered to be the misguided implementation of the CDC
guidelines by state governments, insurance companies, and physicians. In its introduction, the
task force wrote that it recognized the utility of the CDC guidelines and its “contribution to
mitigating unnecessary opioid exposure and the adverse outcomes associated with opioids. It
also recognizes unintended consequences that have resulted following the release of the
guidelines in 2016, which are due in part to misapplication or misinterpretation of the guideline,
including forced tapers and patient abandonment.” They later go on to say, “Clinical practice
guidelines for best practices that only promote and prioritize minimizing opioid administration
run the risk of undertreating pain, especially when the cause of the pain is uncertain or cannot be
reduced through non-opioid approaches... Although effective for moderate to severe acute pain,
the effectiveness of opioids beyond three months requires more evidence.” However, they were
clear in not establishing a ceiling dose, saying “The idea of a ceiling dose of opioids has been
recommended, but establishing such a ceiling is difficult, and the precise level for such a ceiling
has not been established.”
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The recommendations from the Inter-Agency Task Force will not be the last expert opinion
we hear on this issue. The CDC has announced that it plans to respond to the concerns raised by
multiple medical societies -- including the American Medical Association – and to publish
revised guidelines, likely in early 2022. Unfortunately, they do not have very many new clinical
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trials to inform their new guidelines. Just as in the past, they will have to rely on a disparate
consensus of physicians.

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