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Message from the President about the CDC Guidelines

On Tuesday afternoon March 15th the CDC released the final version of their 2016 Guideline for Prescribing Opioids for Chronic Pain (http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm). American Pain Society members were involved in virtually every step of the development of the guidelines (from literature review, guideline development and formal feedback to CDC on positives and concerns in the two previous drafts of the guideline). As might be expected in a multidisciplinary group such as APS, opinions differ among us on the role of opioids in chronic pain treatment. Unfortunately, due to the absence of any evidence defining both benefits and risks of long term opioid treatment, experience, more than science, had a primary influence in this guideline’s construction. Nonetheless, most of us would agree that guidelines in the area of chronic noncancer pain are important (which is why APS spent considerable time and resources on our own 2009 guidelines on the same topic) and with the primary emphases of the recommendations themselves:

  1. Opioids should not be first line monotherapy for chronic pain (and probably not acute pain either – as our recent Guideline for Postoperative pain reinforced)
  2. When opioids are prescribed, risks and benefits should be carefully weighed and the lowest effective dose utilized for the shortest time possible (as in every other drug therapy I am aware of).
  3. There are some concomitant factors that can increase the risks of opioids (co-administration of sedatives being one factor that is evidence-based and yet commonly seen in practice) and some clinical assessments that MAY reduce risks (e.g., Prescription Drug Monitoring Program checks).
  4. Many of the recommendations seem like “mom and apple pie” to most pain experts. Nonetheless, as a guideline targeting primary care practitioners I have listened carefully to numerous primary care APS members who contend that the simple and high profile nature of these guidelines will help primary care colleagues more effectively use their 7 minute appointments to assess and treat people with complex chronic pain.

So what can an evidence-based society such as the APS and its members do with regard to this largely eminence-based guideline? In general, we can all make sure that we have read the guideline and can teach others what they say and what they DO NOT say. For example:

  1. The doses and times listed in the guideline are not based on risk/benefit studies but on risk studies alone and thus should not be used by prescribers, insurers or the legal system as limitations on therapy for any one patient – or reason to prescribe for that matter.
  2. Despite multiple media reports to the contrary the guideline clearly states that its recommendations regarding acute pain do not refer to pain after trauma or major surgery.
  3. The guideline specifically avoids providing guidance for treating pediatric pain – for better or worse.
  4. The guideline, similarly, gives no guidance for when to consult a pain expert (or even who a pain expert might be).

In short, it is somewhat embarrassing to realize the large gaps in our knowledge regarding the benefits of long-term opioid treatment for chronic pain after all these years. We, the American Pain Society and its membership encourage support and implementation of studies to fill these gaps. Whether or not we like the opinions expressed in the guidelines we should be at the forefront of gathering data to either change or support those opinions.

Gregory Terman
President, American Pain Society