Contradictions in CDC Guidelines

Seedy Sea or CDC? by Jeffrey Fudin – January 12, 2016

This review of the guidelines was written by a professional pharmacist together with his students.

Upon review of the Proposed 2016 CDC Guideline for Prescribing Opioids for Chronic Pain we find various contradicting statements based on the presented evidence and the recommendation strength

According to the National Guideline Clearinghouse, “level A rating requires at least two consistent Class I studies”.

However, all of the 12 recommendations provided are based on case series (level 3 evidence) or expert opinion (level 4 evidence) yet assigned a grade A recommendation. 

For instance, according to the proposal, providers

“should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/ day (recommendation category: A, evidence type: 3)”.

The recommendation is based on one randomized unblinded study8 in 135 patients (94% males; 74% have musculoskeletal pain) who received 40 MME/day compared to 52 MME/day, yet the recommendation was generalized to “chronic non cancer pain” and recommended “to avoid increasing dosage to ≥90 MME/ day” which was not evaluated by the referenced study.

Considering the Rennick study, [Rennick A, Atkinson T, Cimino NM et al. Variability in Opioid Equivalence Calculations. Pain Med. 2015 Sep 9. doi: 10.1111/pme.12920.] it is of particular importance that the standard deviations for fentanyl and methadone “morphine equivalents” will exceed the CDC cut-off by CDC’s own definition of morphine equivalent. 

Looking at this another way, one clinician’s MME in this case could be 59 MME and another clinician might assign the equivalence of 293 MME, a range spanning 234mg of morphine equivalent.

Just the standard deviation alone is a recipe for death in the untrained professional.

Given

1. lack of standardization,
2. potential drug interactions,
3. patient’s physical features such as height and weight, gender,
4. end organ (dys)function,
5. coupled with patient individualized pharmacokinetics due to polymorphism,

we respectfully disagree with utilizing a standard cut-off for morphine dose

instead of improving the knowledge of healthcare professionals, the guideline is placing the burden on patients by reducing opioid access for patients that may legitimately require them

The Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain recommendations may place restrictions on personalized patient care and prevent clinicians from providing high quality of care.

The variability in opioid conversion tools, altered pharmacokinetics; polypharmacy, and drug-drug or drug-food interaction potential, could all complicate medication management within the chronic pain population.

Rennick A, Atkinson T, Cimino NM et al. Variability in Opioid Equivalence Calculations. Pain Med. 2015 Sep 9. doi: 10.1111/pme.12920. [Epub ahead of print]