Professional Criticisms of CDC Guidelines

Responses and Criticisms Over New CDC Opioid Prescribing Guidelines | March 18, 2016

In their statements, both the American Academy of Pain Medicine (AAPM) and the American Medical Association (AMA) first cautiously express approval of the CDC’s intentions (obviously intimidated) before diving into the glaring problems with the guidelines.

I feel the worst part is the fixed dosage limit, unscientific to the point of irrationality and most damaging to patients. It’s absurd to legislate a universal fixed limit since individuals’ responses vary so widely. I personally know of a 6x dose difference between a long-term user and someone who uses it after surgery.

Additionally, many of us have developed tolerance over the years and decades of successfully using opioids for our pain. It makes no sense to hold long-term opioid users and opioid-naive patients to the same dosages.  

Centers for Disease Control and Prevention (CDC) published its own set of clinical guidelines for treating acute and chronic pain in adult patients.1 

However, some have not responded to the CDC’s guidelines with unconditional support. A number of criticisms have been expressed by organizations, like the American Medical Association (AMA) and the American Academy of Pain Medicine (AAPM), that question the validity and quality of the guideline’s featured recommendations.

The criticisms surround the CDC guideline’s low-quality evidence base, which excludes all data from studies investigating opioid efficacy recorded from 3 months to 1 year duration. This is a concerning omission, according to Daniel B. Carr, MD, President of the AAPM, because the guidelines are intended for treating pain that lasts longer than 3 months. By contrast, associations like the Food and Drug Administration (FDA) do accept studies in this longer range.

AAPM Response

In a statement released by AAPM, the association said they cautiously support the efforts of the CDC to address the challenges that often accompany prescribing opioids for chronic non-cancer pain.

“We know that doctors—primary care and pain medicine specialists—are integral in treating pain wisely and carefully monitoring for signs of substance abuse. Abuse and diversion of prescription opioids must be addressed,” said Dr. Carr, Professor of Public Health and Community Medicine at Tufts University. “Opioids are not the usual first choice for treating chronic non-cancer pain, but they are an important option—as part of a comprehensive multidisciplinary approach— that must remain available to physicians and appropriately selected patients.”

Dr. Carr said that society needs to address both chronic pain and its treatment as public health challenges. This view is endorsed by the National Academy of Medicine and outlined in the draft National Pain Strategy from the NIH.

“Public health problems are typically complex; well-meaning, but narrowly targeted, interventions often provoke unanticipated consequences,” he said. “We share concerns voiced by patient and professional groups, and other Federal agencies, that the CDC guideline makes disproportionately strong recommendations based upon a narrowly selected portion of the available clinical evidence.

It is incumbent upon us all to monitor the deployment of the guideline to ensure that it does not inadvertently encourage under-treatment, marginalization, and stigmatization of the many patients with chronic pain that are using opioids appropriately.”

AMA Response

In a statement released by the AMA, Patrice A. Harris, MD, the AMA board chair-elect and chair of the AMA Task Force to Reduce Opioid Abuse, said that “while we are largely supportive of the guidelines, we remain concerned about the evidence base informing some of the recommendations, conflicts with existing state laws and product labeling, and possible unintended consequences associated with implementation, which includes access and insurance coverage limitations for non-pharmacologic treatments, especially comprehensive care, and the potential effects of strict dosage and duration limits on patient care.”

That sums up the many problems with these guidelines well. The absurdity of this whole effort is an affront to science and reality (anyone could suddenly suffer a painful condition), a blatant case of industry influence (the “recovery” industry is booming) , a complete failure to acknowledge reality (overdoses are from addiction, not pain care), and an impending disaster for people with persistent and significant pain (opioids are the most effective pain relief).

I’m sure many pain patients are at this very moment wishing their pain upon the sadistic bureaucrats who crafted this policy, which essentially legalizes torture.

I don’t normally advocate for wishing anything but equanimity and happiness upon other people, but this is different. I almost see it as my spiritual obligation to help correct all the misunderstandings, 99% of which come about because pain-free people cannot understand chronic pain.

It’s not about revenge or punishment, but about evidence. These people know nothing of everlasting torment like we do. They need to be educated, to develop experience, and to gain deeper insights into pain that lasts longer than 3 months, so they can make more appropriate policies about opioid pain relievers.

Since they believe all pain can be treated the same, I feel obligated to enlighten them. So I’m trying to mentally/spiritually/telepathically send these folks the exact feeling of my specific pains so they too can experience the infinite variety of pain’s textures and torments.

“We know this is a difficult issue that doesn’t have easy solutions and if these guidelines help reduce the deaths resulting from opioids, they will prove to be valuable. If they produce unintended consequences, we will need to mitigate them,” she noted. “They are not the final word. More needs to be done, and we plan to continue working at the state and federal level to engage policy makers to take steps that will help end this epidemic.”

CDC Defends Guidelines

On the heels of the CDC guideline’s debut in JAMA this week, Thomas R. Frieden, MD, MPH, director of the CDC, and Debra Houry, MD, MPH, director of the CDC’s National Center for Injury Prevention and Control (NCIPC) addressed such concerns raised by organizations in a new perspective piece featured in The New England Journal of Medicine.

“the guideline uses the best available scientific data to provide information and recommendations to support patients and clinicians.”

This is such a blatant lie that I’m not going to bother marking up the rest of their points. I’m too disgusted to read it again.

They cited longer term studies that have shown poor results for opioid therapy, such as a 3-year observational study of postmenopausal women that found less likelihood of pain or functional improvements3 and an observational case-control study that found an association between long-term opioid therapy and higher levels of preoperative hyperalgesia.4

“Whereas the benefits of opioids for chronic pain remain uncertain, the risks of addiction and overdose are clear.” Nearly all opioids on the market are full mu-opioid receptor agonists, making them “no less addictive than heroin,” and although abuse-deterrent formulations may help prevent product tampering, the drugs are still just as addictive and overdose-capable through oral intake, they wrote.

“Management of chronic pain is an art and a science. The science of opioids for chronic pain is clear: for the vast majority of patients, the known, serious, and too-often-fatal risks far outweigh the unproven and transient benefits,” they stated.

To read the full perspective article authored by Drs. Friedman and Houry is available through the New England Journal of Medicine right here. The CDC guideline can be accessed for free from JAMAby clicking here. The CDC guideline is the result of collaboration among the CDC’s Core Expert Group and numerous professional organizations featured in the Stakeholder Review Group, which the AAPM is a member. To find out more information about the methodology behind the CDC guideline, click here.