Experts: CDC should restore guideposts to opioid advice

Removing dosing guidance from a guideline summary takes a valuable tool from prescribers, says Dr. Mark Sullivan and pain-medicine colleagues.

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A group of pain-medicine experts is urging the U.S. Centers for Disease Control and Prevention to restore dosing recommendations to the summary portion of its 2022 opioid guidelines.

The move would give primary care physicians (PCPs) the help necessary to decide how to treat patients with chronic pain. Primary care doctors prescribe the lion’s share of pain medications, but have less education in the area than anesthesiology and pain management specialists.

“We say that we need these guideposts,” University of Washington School of Medicine psychiatrist Dr. Mark Sullivan said. “They're very helpful to primary care docs.”

Sullivan was lead author of an essay on the topic, published July 17 in JAMA Internal Medicine.

While the dosing recommendations remain in the 2022 document, the CDC removed them from a bulleted summary. Sullivan noted, however, that a poll of PCPs showed that they found similar dosing guidance in Washington state guidelines extremely helpful.

“As you can imagine, 95% of people who look at the guidelines will only read the bullet points,” he said. “It's not generally a specialist who does the prescribing; it’s primary care, and they don't have the time to read the whole document. We're saying that these modifications have weakened these guidelines in an important way.”

Sullivan said the inclusion of the dosing recommendations in 2016 led to problems because they were implemented as hardline stops by some insurance companies and health systems. That caused some patients to suffer opioid withdrawal and loss of necessary care.

The CDC’s new focus on shared decision-making is well-meaning, but is setting up other problems, the essay’s authors contend. For instance, people who have taken opioids for a long time might be unreliable in evaluating the drugs’ effect on their pain due to dependency.

“We say that shared decision-making is valuable,” Sullivan said. “It's a foundation for good care, but it is insufficient in opioid prescribing and does not protect patients enough. Opioids are not like blood pressure pills or diabetes pills. They are controlled substances that induce dependence on them. They change decision-making.”

An editor’s note accompanying the essay noted that Sullivan and colleagues’ opinion might be controversial.

“One of the values of medical journals is to encourage discussion of difficult issues,” they wrote. “Whether or not you agree with the perspective of these authors, we believe that it is important for this view to be heard.”

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