Are CDC Guidelines Too Liberal Around Prescribing Opioids?

Most find them 2022 CDC Opioid Guidelines, Also published in the New England Journal of Medicinesimilar to the 2016 CDC guidelines. But a new comment worries me and reinforces my concern that previous recommendations were too liberal. The newer version, in my opinion, more clearly tolerates the initiation of opioids into them don’t take them already. From page 26 (there are caveats about opioids below):

This does not mean that patients should be required to sequentially fail non-pharmacological and non-opioid pharmacological therapy or be required to apply a particular treatment before continuing opioid therapy.” (Italic is mine).

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

Source: Wellcome Collection Gallery/CC-BY-4.0

The 2022 statement complements the already lenient 2016 comment on newly introduced opioids. This now even more strongly suggests that clinicians need not try non-opioid treatments of any kind before starting opioids—that physicians can use opioids as first-line therapy without even trying aspirin.

However, the question of the political context arises. The CDC saw a significant impact from the 2016 recommendations: Through no fault of their own, scores of clinicians misinterpreted the guidelines and began rapidly reducing or abruptly discontinuing opioids in patients, sometimes giving them up altogether. Widespread psychological and physical harm followed.

This prompted the authors of the 2016 guidelines and others to clarify these patients already taking opioids should not be abruptly reduced or discontinued. They emphasized that any cuts should only be made after careful negotiation with the patient. And that these often fragile patients are carefully screened for addiction to opioids (and often other legal and illegal substances), physical and psychological addiction to opioids, and possible abuse, such as abuse. B. the sale, must pay attention. In addition, many suffer from significant depression and anxiety disorders that require treatment.^1.2

To be fair to the authors, both the 2016 and 2022 versions explain at length that prescription opioids for chronic pain have none proven value or research support to remind readers that opioids have terrible adverse effects; for example over 200,000 deaths from prescription doctors. The authors also emphasized that clinicians should not use opioids as first-line treatment. The much greater emphasis on policy on the opioid-avoiding side of the story speaks to the message I suspect the authors are trying to convey without political pressure: Do not start opioids in patients who have not taken them before.

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

So what’s my problem with a sentence? GPs prescribe most opioids, but they lack even the basics of mental health education, let alone chronic pain and opioid use, as I discuss at length in a previous post.

Unfortunately, many of these same clinicians were using opioids in patients suffering from the above effects. We must break this beaten path, not condone it. If used at all in opioid-naïve patients, I suggest that only well-trained addiction, mental health, and pain specialists should begin using opioids in patients. While I understand the political pressure, the CDC shouldn’t even hint at the option for untrained clinicians to introduce opioids to patients.

So what should the doctor do? My group has developed evidence-based guidelines, which I have summarized in a previous post and presented on a larger scale in a new textbook. Following these guidelines has been shown to be more effective than starting opioids.

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