CDC Opioid Guidelines Address Integrated Care but Leave Access Worries Intact

March 17, 2016

by Amanda Conschafter, blog editor

Following a lengthy and controversial process, the Centers for Disease Control and Prevention issued new guidelines Tuesday on prescribing opioids for pain. Designed to guide primary care providers on when, at what doses and for how long opioid pain medications are appropriate, the guidelines present 12 principles meant to reduce overprescribing. The CDC document acknowledges the value of balanced pain care and, aptly, the challenge of health plan barriers. But for some patient advocates, the recommendations are still too prescriptive, raising concerns about access for patients with debilitating pain.

Guidelines at a Glance

  • Multimodal and integrated pain care. Though the guidelines seek to reduce opioid prescribing, they do acknowledge the need for multimodal and integrated pain care. They point out the value of non-pharmacologic approaches, such as exercise and talk therapy, and non-opioid pain treatments, such as epidural injections, certain antidepressants, NSAIDs (like acetaminophen) and COX-2 inhibitors.
  • Cost misconceptions. The guidelines also debunk the myth that opioid-only treatment is cheaper than more long-term, multi-faceted approaches to pain. “Many pain treatments, including acetaminophen, NSAIDs, tricyclic antidepressants, and massage therapy,” the guidelines states, “are associated with lower mean and median annual costs compared with opioid therapy.”
  • Use of opioids. “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain,” the guidelines explain. In cases where opioid treatments are warranted, the CDC advises physicians to start with the lowest dose and limit opioid treatment duration. CDC Director Thomas Friedan summarized the guidelines’ message as “Start low and go slow.” Physicians are also advised to apply a broader, integrated approach to pain management when they do prescribe opioids.
  • Coverage barriers. The guidelines acknowledge that health plans to do not always or fully cover other pain treatments, despite their efficacy and low risk for patients.

Access Concerns

While the CDC’s guidelines embrace balanced pain management, they could nevertheless pose significant access barriers for patients.

Consider, for instance, the CDC’s guidance that three days’ worth of opioids should be sufficient for most patients and that more than seven days’ worth of opioids are rarely justified. Though meant as a benchmark to guide physician judgment, the measures could be interpreted or codified as hard limits – tying physicians’ hands. Though guidelines are non-binding, insurers often use them to mold coverage policies. And, as explained by the New York Times, health care providers may rigidly adhere to the guidelines out of fear of lawsuits.

Thus, the American Medical Association explained that it remains “concerned” by the guidelines, while American Cancer Society Cancer Action Network President Chris Hansen voiced concerns for the guidelines’ impact on cancer survivors. “Pain does not end when an individual completes treatment,” Hanson noted. (While the guidelines do not apply to cancer patients, they do extend to cancer survivors and other patients facing long-term and debilitating pain.)

CDC explains that it “is committed to evaluating the guideline to identify the impact of the recommendations on clinician and patient outcomes, both intended and unintended, and revising the recommendations in future updates when warranted.”

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