This post is extremely long, and I apologize. But you should, if you read and study this, understand why nothing is getting accomplished in the realm of pain management, and nothing will if people stay on the CDC guidelines track.
I’m sure, if you are reading this post, you are aware of the CDC guidelines. The first was published in 2016. Since then, the “experts”, or at least those advocates most of you follow, have been touting the CDC guidelines as the reason for the attacks on pain management doctors and pain patients. I, on the other hand, do not follow their rabbit trail because, due to my research, investigation, and knowledge of traditional medicine, know that the problem is the Controlled Substance Act, and the ONLY solution to the current pain management problem is to recognize the fact that no drug causes addiction and get the CSA repealed.
In November, 2022, the CDC revised the guidelines for pain management. Other non-DoC advocates still attack them, saying they aren’t enough. It’s obvious to me that they are not enough to end the attacks, but that is because they don’t address the cause. But, to engage in any worthwhile discussion and help the average pain patient or doctor understand the worthlessness of following them, I decided to read and compare the two guidelines and then state my opinion on what effect the new ones will have on pain management. So here goes.
Differences between 2016 & 2022 CDC guidelines
| 2022 | 2016 |
| Recommendations for all clinicians providing pain care, for managing acute, subacute, and chronic pain. | Recommendations for primary care physicians prescribing for chronic pain |
| Added: CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. | |
| This clinical practice guideline provides recommendations but does not replace clinical judgment and individualized, patient-centered decision-making. | |
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This clinical practice guideline provides voluntary clinical practice recommendations for clinicians that should not be used as inflexible standards of care. The recommendations are not intended to be implemented as absolute limits for policy or practice across populations by organizations, health care systems, or government entities.
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| 5 Primary questions: 1. Effectiveness of long-term opioid therapy vs placebo, no therapy, or nonopioid therapy. 2. Risks of opioids vs placebo or no opioids on abuse, addiction overdose, and how harms vary by patient categories 3. Comparative effectiveness of opioid dosing strategies 4. Accuracy of predicting risk for overdose, addiction, abuse or misuse; effectiveness of risk mitigation strategies 5. Effects of prescribing opioid therapy vs not prescribing opioid therapy for acute pain on long-term use. |
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| Category A recommendations indicate that most patients should receive the recommended course of action; category B recommendations indicate that different choices will be appropriate for different patients, requiring clinicians to help patients arrive at a decision consistent with patient values and preferences and specific clinical situations. | Category A recommendations indicate that most patients should receive the recommended course of action; category B recommendations indicate that different choices will be appropriate for different patients, requiring clinicians to help patients arrive at a decision consistent with patient values and preferences and specific clinical situations. |
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Summary less stark: · A number of nonpharmacologic treatments and nonopioid medications are associated with improvements in pain, function, or both comparable to improvements associated with opioid use · Evidence on long-term effectiveness of opioids remains very limited
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In summary, · No evidence shows a long-term benefit of opioids in pain and function versus no opioids.
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Recommendation 1 (acute pain) Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy. |
Recommendation 1. (chronic pain) Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate |
| Recommendation 2 (Subacute & chronic pain Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. |
Recommendation 2 Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety. |
| Recommendation 3 When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids |
Recommendation 4 When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids |
| Recommendation 4 When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. |
Recommendation 5 When opioids are started, clinicians should prescribe the lowest effective dosage. |
| Recommendation 5 For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages |
Recommendation 7 Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids |
| Recommendation 6 When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids |
Recommendation 6 Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed |
| Recommendation 7 Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients |
Recommendation 7 Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids |
| Recommendation 8 Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone |
Recommendation 8 Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose |
| Recommendation 9 When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose |
Recommendation 9 Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months |
| Recommendation 10 When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances |
Recommendation 10 When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs |
| Recommendation 11 Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants |
Recommendaton 11 Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible |
| Recommendation 12 Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death |
Recommendation 12 Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder |
| Management of Opioid Misuse that Does Not Meet Criteria for OUD Does not automatically require tapering. |
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| Pain Management for Patients with OUD Use nonpharmacologic and nonopioid pharmacologic pain treatments as appropriate. Consider buprenorphine or methadone treatment. |
The 2022 guidelines identify 4 key areas for prescribing opioid pain medication:
1)determining whether or not to initiate opioids for pain;
2) selecting opioids and determining opioid dosages;
3) deciding duration of initial opioid prescription and conducting follow-up; and
4) assessing risk and addressing potential harms of opioid use.
In addition, five guiding principles were identified to inform implementation across recommendations. These guiding principles focus on
1) the appropriate treatment of pain;
2) flexibility to meet the care needs and clinical circumstances of each patient;
3) a multimodal and multidisciplinary approach to pain management;
4) avoiding misapplication of the clinical practice guideline beyond its intended use; and
5) vigilance in attending to health inequities and ensuring access to appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain treatment for all persons.
A central tenet of the 2022 guideline is that acute, subacute, and chronic pain needs to be appropriately and effectively treated regardless of whether opioids are part of a treatment regimen. Clinicians should select nonpharmacologic or pharmacologic treatment modalities, or both, that maximize patient safety and optimize outcomes in pain, function, and quality of life. A multimodal and multidisciplinary approach to pain management that considers the biologic, psychological, and social characteristics of each person is critical. The care provided needs to be individualized and person centered. Clinicians and patients should work together to identify treatment goals, including functional goals, and tailor an approach that considers both the benefits and risks of available options. Progress should be monitored over time and treatment protocols adjusted accordingly. Health systems and payers can work to ensure multimodal treatment options are available, accessible, and reimbursed for patients. Public and private payers can support a broader array of nonpharmacologic interventions such as exercise, multidisciplinary rehabilitation, mind-body interventions, cognitive behavioral therapy, and certain complementary and integrative medicine therapies.
They go further by stating:
To avoid unintended consequences for patients, this (2022) clinical practice guideline should not be misapplied, or policies derived from it, beyond its intended use. Examples of misapplication or inappropriate policies include being inflexible on opioid dosage and duration, discontinuing or dismissing patients from a practice, rapidly and noncollaboratively tapering patients who might be stable on a higher dosage, and applying recommendations to populations that are not a focus of the clinical practice guideline (e.g., patients with cancer-related pain, sickle cell disease, or during end-of-life care)
Criticisms
As soon as the guidelines were published, an article by Leo Beletsky, JD, MPH, and Kate M. Nicholson, JD, CDC’s Updated Opioid Guidelines Are Necessary, but Not Sufficient was published in MedPageToday. They recognize what I saw, that the new guidelines emphasize flexibility in pain pharmacotherapy and rejects the controversial dose and duration limits that had been widely misinterpreted by policymakers. It also rightly urges careful balancing of benefits and risks and the expanded use and coverage of other treatments. But recognizing the good, appropriate standards recognized by the new guideline did not stop the rabbit chase. They proceeded to blame the 2016 guidelines for the attacks by the DEA on pain management, ignoring the fact that opioids have been attacked since 1998, being focused on by the DEA in 2002, almost 2 decades before the guidelines.
At least they recognize the fact that, in spite of the 2019 statement by the CDC against misapplications of its 2016 guideline, there was no slowing in the number of patients suffering harm. They also recognized the fact that the problem continues, even following the Ruan/Kahn SCOTUS decision, that doctors continue to be raided by the DEA.
Their solution, though, will also get us nowhere.
Meanwhile, 38 states have already based their laws and policies that dictate how health care practitioners may treat patients in pain on the 2016 Guidelines. So the new guidelines mean absolutely nothing in those states as far as law enforcement is concerned. In this article, Florida rejects the CDC’s New Opioid Guidelines, the Florida deputy secretary for health, Kenneth Scheppke, spews fake government propaganda against opioids and states that Florida rejects the new 2022 CDC guidelines, stating that “it isn’t the time for the CDC to relax its opioid recommendations.”
Similarly, on December 21, 2022, JAMA published an article titled Will the New CDC Opioid Prescribing Guidelines Help Correct the Course in Pain Care? They state that the new guidelines are aimed at helping primary care physicians and other clinicians offer safe and effective treatment for adults with acute, subacute, and chronic pain, while reducing risks associated with opioids. The 2022 guidelines reflect this in several ways. The main recommendations omit mention of specific upper dosage limits, offer guidance on how to work with patients to slowly and carefully taper opioid medication when appropriate, and emphasize talking with patients about opioid therapy’s risks and benefits while setting realistic treatment goals. They also suggest use of nonopioid multidisciplinary therapies and urge regular reevaluation of both the patient and the treatment plan, keeping in mind each individual’s pain and function. And the guidelines recommend offering treatment for patients with opioid use disorder.
In this article, Cindy Steinberg, director of policy and advocacy for the US Pain Foundation, mentions an interesting source of information for us, the HHS Pain Management Best Practices Inter-Agency Task Force Report, published in 2019 in response to the backlash surrounding the previous guidelines. Steinberg served on the congressionally mandated task force, which helped to inform the development of new Centers for Medicare & Medicaid (CMS) bundled codes for multidisciplinary chronic pain treatment. The codes go into effect on January 1, 2023, and are meant to increase patient access to holistic pain therapies. Steinberg added that the CDC missed an opportunity to spotlight the HHS report in their new guidelines.
Cindy also published an interview with her in an article on Nov. 8, 2022 by her organization HERE, in which she states that the new 2022 guideline does not go nearly far enough in correcting the serious problems that arose from the 2016 Guideline, and will not make a difference in future pain management.
Her concerns are that
- The Guideline is based on fundamentally weak scientific evidence.
- The exemption of certain pain conditions as being more worthy of pain control where the stated “risks” and “harms” don’t apply is wrong.
Pain is pain. - Cautions and warnings regarding increasing dosages above 50 milligrams morphine equivalence (MME) are arbitrary and unscientific, and have caused widespread harm, including prosecution of doctors who prescribe above those amounts and forced tapering of patients who are receiving dosages above this arbitrary amount.
- The Guideline has clear bias against opioid therapy, continually emphasizing the perceived risks and harms while failing to discuss any benefit for pain relief when taken appropriately under medical supervision.
- The Guideline fails to acknowledge the risks and harms of enduring prolonged pain when other therapies have proven inadequate or contraindicated.
Jeffrey Singer, in his article The CDC Replaces Flawed 2016 Opioid Prescribing Guideline with a Flawed 2022 Opioid Prescribing Guideline states that, “The CDC goes to great lengths to stress that the document is meant to serve as a list of suggestions and recommendations and is by no means intended as a mandate, emphasizing that physicians should use their best clinical judgment to provide individualized treatment to their patients. However, he commented, “the CDC guideline will inevitably become interpreted and adopted as hard and fast rules by state and local governments, pharmacies, health plans, and third-party payers, despite guideline warnings against doing so.”
What I agree with is his comment that “Perhaps most egregiously, the rationale of the 2022 Guideline remains predicated on the flawed assumption that overprescribing opioids caused the overdose crisis. There is no correlation between prescription volume and the nonmedical use or addiction to prescription opioids.” But he doesn’t recognize the fact that drugs, themselves, are not the cause of addiction at all. And that is what we have to get across to the nation to end the attacks.
My opinion
Other advocates have criticized the 2022 guidelines stating that they have lowered the 90mme on the 2016 guidelines to 50mme, and that is bad. The references to 50 mme that I have found are on p. 55. But they don’t exclude higher dosing. They just say that if higher doses are needed the clinician should reassess the benefits and risks, and increase dosage by the smallest practical amount. That is just proper pain management. Naturally the studies they cite showing dosages between 50 and 90 mmes show minimal improvement are cherry-picked because of those findings. Typical conventional medicine technique. A study will show whatever the creator wants it to show.
They also state that the clinician should implement additional precautions, such as increased frequency of follow-up and offer naloxone and overdose prevention education. These are reasonable suggestions.
Some states have actually put MME thresholds into state law, so they also recommend that the clinician be aware of these state policies. Definitely smart.
They also give great recommendations on tapering so that patients are not tapered too quickly or taken off opioids entirely without a taper.
Although 50 mme is mentioned 24 times in the guidelines, it is basically just a point of reference, not a ceiling.
My overall opinion is that the 2022 CDC guidelines will not change a thing. Because it is not the cause of the attacks on doctors. The cause of the attacks on doctors is the Controlled Substance Act, and to end the attacks, the CSA must be repealed. That will make the DEA defunct and be closed down. That will save billions of dollars in costs to US taxpayers. Once the CSA is repealed, visits to pain management will not have to be conducted monthly, saving billions of dollars in healthcare costs. Drugs that are natural and helpful will be available over the counter, or with pharmaceuticals that are less costly. There won’t be a need for illicit drugs, so the drug cartels will fizzle. The boarder issue will lighten, as people will not have to leave their country to escape attacks by the drug cartels. Those who can’t make a living in their country can start raising crops for legal drugs. Why can’t people see that this is the answer, and stop chasing the rabbits?
Linda Cheek is a teacher and disenfranchised medical doctor, turned activist, author, and speaker. A victim of prosecutorial misconduct and outright law-breaking of the government agencies DEA, DHHS, and DOJ, she hopes to be a part of exonerating all doctors illegally attacked through the Controlled Substance Act. She holds the key to success, as she can offset the government propaganda that drugs cause addiction with the truth: The REAL Cause of Drug Abuse.
Get a free gift to learn how the government is breaking the law to attack your doctor: Click here to get my free gift
“ Once the CSA is repealed, visits to pain management will not have to be conducted monthly, saving billions of dollars in healthcare costs. Drugs that are natural and helpful will be available over the counter, or with pharmaceuticals that are less costly. There won’t be a need for illicit drugs, so the drug cartels will fizzle. The boarder issue will lighten, as people will not have to leave their country to escape attacks by the drug cartels. Those who can’t make a living in their country can start raising crops for legal drugs.”
Linda this sounds like a utopian prophecy, it’s musical 😉
Imagine the reprive for ALL the peoples of South & Central America if the US just ended the drug war. The Washington immigration hawks might go catatonic 🖤
Thank you for gathering and sharing this information!
Having been in pain all of my life, I have followed the “opioid epidemic” closely, while living in Constant Pain for many, many years.
In my research I have recently found that there is no longer any Profit for the Drug Companies in manufacturing Opioids anymore.
Therefore, they won’t. Case Closed. It’s Always About The Money.
They are hard at work now trying to find A New Pain Drug upon which they can Profit.
Follow the Money.
That’s where the truth lies.
The problem is that it is all about the money to the government. “Go to where the money is and the guns aren’t” is why they turned from illicit drugs to doctor’s offices.
Practically all the recommendations and concerns were addressed and answered by FDA by using clinical trials for each formulation: solids, patches and liquid.
As someone that has spent decades in an FDA regulated Analytical laboratory the work is exhaustive and required many man work hours. Also we kept a full time statistation on site. The only explanation that CDC hired an outside agency is that CDC does not even have the staff nor the experience to perform such work.
FDA analysis even includes metabolism graphs.
The CDC is just trying to hijack prescribing authority from FDA. FDA wrote the book.
Clandestine fentanyl and methamphetamine causes more family problems and death than prescription opioids. However, there is no in trying to fix these problems. The Bureau of VItal Statistics told me in an email that AK imported Heroin overdoses into his Rx overdose database. That is fraud and unscientific behavior.
That son of a bitch.
I’m limited in travel to fight this monstrous cruel “guidelines”.
But I will write my Congressman about this terrible CSA!!!!