Potential Misapplication

Misuse of the guideline, according to CDC officials, has included applying its recommendations to patients in active cancer treatment, those experiencing acute sickle cell crises or patients suffering post-surgical pain.

Various other organizations are currently working to develop guidance for treatment of pain in these subgroups of patients, Rich said.

"The pain treatment requirements for the management of pain in these groups could easily surpass the 90 MME (morphine milligram equivalents) recommendation -- the suggested top end of dosing in patients for chronic pain from the CDC guideline," he said. "The circumstances surrounding pain in each of these groups is different from (those of) the typical patient with chronic pain, and each group must be considered individually for the relief of pain and suffering."

Other examples of misapplication have included instituting hard limits on, or even cutting off, opioid use in patients already prescribed higher dosages -- 90 MME or more per day. The agency said that its recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.

The CDC identified the 90 MME per day threshold as a soft cutoff based on data showing that the risk of accidental overdose and other complications increases exponentially after that level, Rich said.

"In patients not previously exposed to opioids, this remains a goal that I fully endorse -- keeping the patient to the lowest effective dose based upon an ongoing assessment of pain and function," he said. "For those patients already taking opioids for chronic pain, many are already at or above that level, and efforts to limit those patients to 90 MME per day could easily precipitate worsened pain and lessened functional capacity."

Furthermore, said Rich, rapid tapers or abrupt discontinuation of opioids in patients already dependent on the medication for pain control will precipitate opioid withdrawal, which is clearly painful and dangerous for patients.

"In an effort to lessen the effects of withdrawal, the patient may turn to street drugs or other inappropriate medications with other unintended consequences," he noted.

One other significant misapplication of the guideline is that its dosage recommendation does not apply to patients receiving or starting medication-assisted treatment for opioid use disorder. It applies only to use of opioids to manage chronic pain.

"The CDC guideline primarily focused on the treatment of chronic pain, and the subject of MAT for the treatment of opioid use disorder is a separate issue, which is better addressed by other guidelines," Rich said.

The agency said in its statement that the guideline was intended to ensure that primary care clinicians work with patients to consider all safe and effective treatment options for pain management.

"The CDC encourages clinicians to continue to use their clinical judgment, base treatment on what they know about their patients, maximize use of safe and effective non-opioid treatments and consider the use of opioids only if their benefits are likely to outweigh their risks," said the statement.