Pain patients could see impact from CDC’s new opioid prescribing guideline :

Oxycodone pills

Mark Lennihan/AP

hide caption

toggle caption

Mark Lennihan/AP

Oxycodone pills

Mark Lennihan/AP

Doctors will soon have new guidelines from the Centers for Disease Control and Prevention on how and when to prescribe opioids for pain.

Those guidelines – currently under review as a draft – will serve as an update to the agency’s previous advice on opioids, issued in 2016. That advice is widely blamed for leading to harmful consequences for patients with chronic pain.

Federal officials have acknowledged their original guidance was often misapplied; it was supposed to serve as a roadmap for clinicians navigating tricky decisions around opioids and pain — not as a rigid set of rules.

But the 2016 version was used as the basis for sweeping policy decisions, as lawmakers and health leaders struggled to contain the nation’s overdose crisis. Many states adopted laws and regulations that set limits on prescribing, and health insurers also crafted policies to that effect.

And doctors grew wary of giving opioids at all, which often led to sudden disruptions of treatment, resulting in physical and mental agony, and even a heightened risk of suicide.

The restrictive climate around prescribing has persisted, says Cindy Steinberg, director of national policy and advocacy for the U.S. Pain Foundation.

“I hear from patients every week and doctors just don’t even want to see pain patients,” she says. “It’s a really tough situation out there.”

This is why the agency’s revised guidance is now under scrutiny. The public comment period ends on Monday, and then the agency will weigh its final recommendations.

Some experts see the proposed changes as a promising step toward addressing the harms suffered by pain patients in the wake of the previous guidelines. And yet many others, including patients with chronic pain, argue that the guidance is still flawed — with the potential of being misinterpreted and misapplied.

A step in the right direction

The new proposed guidelines — a sprawling, 200-page document — continue to advise against using opioids for pain when possible and to take a cautious approach when it’s necessary, given the risks of opioid misuse and overdose.

But there are some notable changes from the old guidance.

The topline recommendations — often the takeaways for clinicians and policymakers — no longer include specific limits on the dose and duration of an opioid prescription that a patient can take.

“That’s an important change,” says Dr. Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham.

With the original guidelines, “it turned out that insurance companies and regulators seized on those numbers as simple tools to force changes to care that often were not safe for patients,” he says.

The new guidelines also emphasize that clinicians should use their own judgment in deciding what will be a safe and effective dose for each patient. The authors state upfront that it’s not “intended to be applied as inflexible standards of care” or as “law, regulation or policy that dictates clinical practice.”

Kertesz believes that is a much needed recognition of how the previous guidelines were misapplied, especially to patients already on a stable regimen of opioids for chronic pain.

“The CDC’s changes are really an effort to ameliorate that without losing track of the fact that these medicines were vastly overused and oversold for a period of decades,” he says.

Indeed, the proposed guidelines steer doctors away from using opioids as a first-line therapy for many common acute pain conditions — among them, lower back pain, musculoskeletal injuries and pain related to minor surgeries. It also discourages using opioids for chronic pain, but acknowledges that opioid therapy can play a role in treatment, in particular if other approaches have been tried.

“We’re trying to be very explicit about the fact that these are not meant to be hard thresholds,” says Dr. Roger Chou at Oregon Health & Science University and an author of the 2016 guidelines and the updated version.

Chou notes the evidence still shows an increased risk of opioid misuse and overdose as the dose goes up and that the benefits seem to be pretty small. However, he says their 2016 guidelines were often applied in ways that they had warned against, for instance for patients who had cancer pain.

“It’s sometimes difficult to…