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New draft guidelines for primary care and other clinicians proposed by the CDC Thursday no longer promote hard thresholds on opioid prescribing.

The draft guidance for acute, subacute, and chronic pain is part of a proposed update to the controversial for chronic pain. The 2016 guideline was interpreted as setting medication dose and duration limits and was misapplied by some organizations, leading CDC researchers to attempt to clarify the document in 2019.

The new guideline isn't designed to replace clinical judgment, but is a tool to help providers and patients make safe, effective pain care decisions and provides "voluntary recommendations on the use of opioids to treat pain," the CDC noted.

It is not intended to be applied as an inflexible standard, the agency added. It's also not intended to lead to rapid opioid tapering or discontinuation, and does not apply to sickle cell disease-related pain, cancer pain, and palliative or end-of-life care.

"I was very pleased to see clear language that the proposed guideline is not a replacement for clinical judgment or individualized, person-centered care," noted pain specialist Beth Darnall, PhD, of Stanford University School of Medicine.

"This is crucial, as misapplications of the 2016 guideline centered around a reductive focus on dose-based limits and tapering that was associated with patient harms," Darnall told 番茄社区.

For years, groups like the American Medical Association (AMA) have urged the CDC to reconsider the 2016 guideline. "The CDC's new draft guideline -- if followed by policymakers, health insurance companies, and pharmacy chains -- provides a path to remove arbitrary prescribing thresholds, restore balance, and support comprehensive, compassionate care," said Bobby Mukkamala, MD, chair of the AMA board of trustees, in a statement.

"The previous guidance has harmed patients with chronic pain, cancer, sickle cell disease, and those in hospice," he noted. "The restrictive policies also failed patients who are stable on long-term opioid therapy, and it has denied care to post-surgical patients and those with an opioid use disorder."

The old guideline did nothing to stem the drug overdose epidemic, Mukkamala added. "In fact, the epidemic has become more lethal despite the CDC restrictive guideline due to illicitly manufactured fentanyl, fentanyl analogs, heroin, methamphetamine, and cocaine," he said.

The new 200-page document indicates that opioids should not be considered as first-line or routine therapy for subacute or chronic pain, and points out that non-opioid therapies often are better for many types of acute pain. When the severity of acute pain warrants opioids, the lowest possible dose of immediate-release opioids should be used.

The draft guideline authors found insufficient evidence to determine the long-term benefits of opioid therapy for chronic pain beyond 1 year. "Before starting opioids for subacute or chronic pain, clinicians should discuss with patients the known risks and realistic benefits of opioid therapy, work with patients to establish treatment goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh risks," they wrote.

The updated guideline is through April 11. "This is everyone's opportunity to read this draft document, consider it in the context of our country's current situation, learn from past policy mistakes, and then offer feedback," Sean Mackey, MD, PhD, chief of the Stanford University pain medicine division, told 番茄社区.

"We want to hear many voices from the public including people living with pain and the healthcare providers who help their patients manage pain," said Christopher Jones, PharmD, DrPH, MPH, acting director for the National Center for Injury Prevention and Control, in a CDC statement. "The ultimate goal of this clinical practice guideline is to help people set and achieve their personal goals to reduce their pain and improve their function and quality of life."

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