The Centers for Disease Control and Prevention (CDC) proposed new guidelines on Feb. 10 for prescribing opioids as painkillers, which would replace the series of rules that were set in 2016, according to the CDC website.
Lewis Nelson, professor and chair in the Department of Emergency Medicine at Rutgers New Jersey Medical School, said he was on the committee that created the 2016 guidelines and has concerns regarding the looseness of the potential new guidelines.
Nelson said the 2016 guidelines were created to address both the risks and benefits of long-term medicinal opioid usage. They were adopted as formal regulations by insurers and other organizations, even though guidelines differ from policies, mandates and rules, he said.
The changes were proposed as a response to concerns regarding how the guidelines lowered the opioid dosages for patients who had previously been receiving high doses, Nelson said.
“While there is some truth to this, it was not the design or intent of the 2016 guidance but rather inappropriate interpretation and implementation,” he said. “Abrupt discontinuation of long-term opioid use is associated with opioid withdrawal and, in this population, a perception of worsening pain.”
Nelson said the two most important changes that were made in the new guidelines were to remove a 90 morphine milligram equivalents (MME) dosage escalation cap and to remove an existing recommendation for clinicians to provide initial prescriptions of opioids to last for only three to seven days for patients with acute pain.
He said the 90 MME dosage cap was intended for patients who did not plan on increasing their opioid dosages beyond that number. Though, he said many patients’ clinicians would inappropriately reduce doses higher than 90 MME in order to be adherent to the guideline.
“Indeed the initial guidance was very clear that this was not to be done, but rather that the 90 MME ceiling recommendation was for patients going up on their opioid dose,” Nelson said. “This dose, 90 MME, was found in multiple studies to be an inflection point where unintended opioid overdose and death escalated.”
He also said that the change to remove the recommendation for prescriptions to last for only three to seven days for patients with acute pain is important because after approximately five days of using prescribed opioids, the risk of long-term usage increases for patients.
“By removing this recommended cap … prescribers may feel it is appropriate to prescribe longer initial prescriptions to their patients,” he said. “This is one of the key factors that created the opioid crisis in the early 1990s that lasted through today.”
Regarding the consequences for patients in need and the state of the opioid epidemic as a whole, Nelson said he is concerned that the new guidelines will increase the rate of opioid use disorders and unintentional opioid overdoses in the U.S.
He said among the new guidelines, patients with chronic pain may be inappropriately placed on higher doses of opioids, which can lead to hyperalgesia, or worsening pain, opioid use disorder or unintentional overdose. This is the same for patients with acute pain who could potentially receive longer initial prescriptions, he said.
Nelson also said that while there are numerically more deaths from fentanyl than there are from prescription drugs, this is arguably due to its greater availability. He said many people who use fentanyl were once prescribed opioids but switched over when physicians lowered their dosages.
“If you look at the trajectory of prescription opioid deaths over the last 20 years, it has stayed largely the same,” he said. “So we still have a prescription opioid crisis, but we also have a fentanyl crisis. The latter is greater, but both epidemics are still very active.”
Nelson said students should be aware of the fine print of these newly drafted guidelines as they remain similar to the 2016 guidelines but allow room for individual practices to interpret them unsafely.
“If you read the extensive detail provided below the bullets, it is very clear that the risk of opioids, in every setting, is greater than the benefit,” he said. “The watered down recommendations in the bullets do not do justice to the grave consequences of continued high dose and long term opioid use.”