The US government proposed new guidelines for prescribing opioid pain medications on Thursday. Of particular importance is that they have removed the previously applied recommended ceilings on doses for chronic pain patients, and instead encourage doctors to use their clinical judgement.
This is a huge change in policy and a massive step forward, as here in Australia the CDC recommended guideline of not exceeding 90 milligrams of morphine equivalent (MME) has been used as justification to force taper chronic pain patients to lower doses of opioids, which has resulted in under-treatment of their pain.
Now the CDC is admitting their previous guideline was flawed and had the unwanted result of chronic pain patients being force-tapered en-mass and even left without health care. The flow-on effect to pain management doctors here in Australia must be to also abandon the ceiling of 90MME daily, and assess each patient’s pain individually and prescribe the lowest dose that controls a patient’s pain.
Of course, the guidelines still heavily recommend that doctors should first try “non-opioid therapies” for both chronic and acute pain, and this is wholly appropriate. I find it very hard to believe that any doctors use opioids as a first-line treatment. Unfortunately, they do recommend that medicine like gabapentin be trialed before opioids, despite gabapentin only being effective on neuropathic pain, and even then the success rate is not high. Gabapentin has a significant side effect profile, including addiction. Also recommended to be trialed before opioids are simple analgesics, such as paracetamol and NSAIDS, as well as physical therapy, massage and acupuncture.
The CDCs previous guidelines are infamous for being widely misinterpreted and misapplied by doctors with many doctors in the US being quick to cut patients off their opioid pain medications, sometimes cold turkey. Some doctors force-tapered their patients, people who had previously been living functional, full lives thanks to their opioid pain medications, forcing them to live with uncontrolled, severe, daily pain. Left with no pain relief and no recourse, some chronic pain patients committed suicide rather than live with the constant, unrelenting pain.
The CDC is now recognising that their guidelines caused unintended harms to chronic pain patients and led to many doctors refusing to prescribe opioid pain medications under any circumstances, thereby withholding a safe, effective therapy from patients who benefited from these medications.
The overriding intent of the new guidelines is to foster individualised patient care. Though still in draft form, the 12 recommendations are a comprehensive revision to the disastrous 2016 recommendations. They aim to walk the line between protecting against the potential harms of opioids and recognising the need for doctors to prescribe opioids in cases of severe pain.
The new guidelines avoid recommending dosages or length of prescription and explicitly warn against abruptly or rapidly discontinuing opioid pain medications for chronic pain patients. While far from pro-opioid and still very heavily recommending tapering off opioids and not starting opioids to begin with, there is at least a recognition in these new guidelines that opioids are beneficial to some chronic pain patients and are both safe and effective with proper monitoring. This has to be seen as a big improvement and hopefully will translate into better pain management.
Here in Australia, we tend to copy what happens in the US, with policy usually lagging about five years behind. We don’t learn from mistakes made in the US, we just blindly follow. In 2020, the Australian government changed the rules around opioid prescribing in Australia, which predictably had the effect of chronic pain patients being force-tapered, forced onto addiction programs, and left to live with unrelenting, severe pain. Exactly as in the US.
We can only hope that the powers that be in the Australian government are taking note of the draft guidelines from the CDC and that it doesn’t take another five years for our own guidelines on the treatment of chronic pain and opioid prescribing to be corrected.
The 2016 CDC guidelines
Media release on the new draft guidelines