The following editorial by local claimant attorney Gregory J. Hubachek and D. Kirkhoff Brainard addresses the Center for Disease Control’s (CDC) opioid prescribing guidelines and how they believe the guidelines’ scientific support is limited.
The CDC opioid prescribing guidelines provoked an immediate and sustained outcry from physicians and pain management specialists as soon as the draft version of the document was released to the public.
The American Academy of Pain Medicine publicly chided the CDC, saying the guidelines were based on “weak or no scientific evidence.” Of the 12 specific recommendations in the CDC’s proposal, the AAPM characterized five of them as based on “low quality evidence” and the remaining seven as based on “very low quality evidence.” High-ranking members of the FDA publicly questioned the CDC’s science and spoke out against the guidelines. 
Since their official publication in March 2016, the guidelines have continued to stir up controversy. Recent studies have challenged the data underlying the CDC’s assumptions about opioid prescribing. A 2016 white paper claims the CDC skewed its findings on opioid drugs by intentionally excluding large-scale clinical studies on opioids from its data set, a practice that is “inconsistent with current regulatory standards.”
Another recent study concludes that the concept of morphine equivalent daily dosage (MEDD) “is unequivocally flawed—thereby invalidating its use empirically and as a tool in prescribing guideline development.” The authors accuse CDC panelists of “misconduct” in including MEDD limits in the opioid prescribing guidelines.
“Although the use of MEDD in research and, to a greater extent, in practice, is probably due to unawareness of its inaccuracy, we posit that the use of MEDD by recent opioid guideline committees (e.g., the Washington State Opioid Guideline Committee and the Centers for Disease Control and Prevention Guideline Committee) in the drafting of their guidelines is based more heavily on disregarding available evidence rather than ignorance.”
Since the CDC guidelines will inevitably exert an effect on society as a whole, not just individual pain patients, the authors warn that the CDC’s MEDD limits may lead to more unintentional overdose deaths, as well as to widespread under-dosing of chronic pain patients.
If they remained only best-practice recommendations to be taken under consideration by physicians before prescribing opioid medications, the CDC opioid guidelines would not continue to generate so much controversy. Given the force of law, however, the CDC guidelines punish patients who are legitimately suffering from severe pain by denying access to pain medicine while failing to provide adequate replacement therapies.
And, as I predicted in 2016, the guidelines became de facto law for certain populations almost immediately after their official publication. Twenty-two states passed new laws or updated existing laws making it tougher for physicians to prescribe opioids to Medicare patients in 2016. The CDC guidelines were almost immediately made mandatory by the Veterans Administration, half of whose 6 million patients report experiencing chronic pain.
The CDC Guidelines as Coercive Tool
Insurers, predictably, are leveraging the CDC opioid guidelines to achieve their own goals of lowering costs and increasing profits.
By virtue of their questionable science, arbitrary restrictions, and apparent lack of concern for patients suffering severe pain, the CDC guidelines dovetail nicely with “closed pharmacy formularies” such as the Official Disability Guidelines (ODG).
Shifting the cost of benefits paid to injured workers from the insurer to the taxpayer is another time-honored industry strategy we wrote about here.
In 2017, the Centers for Medicare & Medicaid Services (CMS) announced a new Opioid Misuse Strategy designed to combat improper prescribing. In addition to mandating that clinicians follow the CDC guidelines, the strategy endorses the idea of “incentivizing prescribing behavior” – essentially encouraging physicians and pharmacists to report suspicious activity by prescribers and patients. This information would then be shared with the private insurers who contract with CMS to cover more than 100 million Americans enrolled in Medicare or Medicaid.
Interestingly enough, the CMS strategy closely resembles a similar strategy set forth in a white paper prepared by a coalition of insurers including Aetna, Anthem, Blue Cross Blue Shield, Cigna, Highmark, Humana, and Kaiser Permanente. 
Opponents of the strategy say it amounts to a license to invade the privacy of both doctors and patients and to mete out punishments by dropping ‘violators’ from their networks or denying coverage to patients.
“Let’s be clear about the CDC guidelines. A major reason the guidelines were developed was to reduce [the] cost of drugs for payers,” says physician Lynn Webster, a former president of the American Academy of Pain Medicine. 
CDC Opioid Prescribing Guidelines – Key Recommendations
The CDC guidelines state that opioid medications “are not first-line or routine therapy for chronic pain.” Clinicians should choose nonpharmacologic therapy and nonopioid pharmacologic therapy as preferred treatments. If opioids are prescribed, “they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.”
If they do prescribe opioid medication, physicians are instructed to:
- Prescribe the lowest effective dose.
- Prescribe only immediate-release opioids.
- Limit prescriptions to the minimum amount required to treat severe pain – usually less than three days and no more than seven days.
- Check the PDMP database to determine if the patient is high-risk for overdose or addiction.
- Avoid prescribing opioids concurrently with benzodiazepines.
- Use urine drug testing before starting opioid therapy and, thereafter, at least annually.
1 Centers for Disease Control and Prevention, “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016,” March 18, 2016.
2 AAPM, “Re: Docket No. CDC-2015-0112; Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain,” p. 3, January 12, 2016, http://www.painmed.org/files/aapm-letter-to-cdc-proposed-2016-guidelines-for-prescibing.pdf
3 Pat Anson, “FDA Endorses CDC Opioid Guidelines,” Pain News Network, February 4, 2016, http://www.painnewsnetwork.org/stories/2016/2/4/fda-endorses-cdc-opioid-guidelines. “Some of the FDA’s own experts have been highly critical of the CDC’s proposed guidelines, which discourage primary care physicians from prescribing opioids for chronic pain. […] Other panel members said they were ‘appalled’ by the guidelines, calling them an ‘embarrassment to the government.’”
4 Ajai Raj, “A Year Later, CDC Opioid Guidelines Still Under Fire,” Pain Medicine News, August 22, 2017, https://www.painmedicinenews.com/Clinical-Pain-Medicine/Article/08-17/A-Year-Later-CDC-Opioid-Guidelines-Still-Under-Fire/42212
5 Michael E. Schatman, PhD; Jeffrey Fudin, PharmD, “The Myth of Morphine Equivalent Daily Dosage,” Medscape, May 24, 2016, https://www.medscape.com/viewarticle/863477
6 Gregory J. Hubachek, “A Bipartisan Prescription for Louisiana’s Opioid Crisis: Part 2,” Louisiana Comp Blog, April 1, 2016, https://compblog.com/guest-post-gregory-j-hubachek-on-a-bipartisan-prescription-for-louisianas-opioid-crisis-part-2/
7 Shefali Luthra, “Hoping to attack opioid epidemic at its source, state Medicaid programs are limiting prescriptions,” STAT, November 23, 2016, https://www.statnews.com/2016/11/23/medicaid-opioid-limits/
8 Pat Anson, “VA to Adopt CDC Opioid Guidelines,” Pain News Network, December 21, 2015, http://www.painnewsnetwork.org/stories/2015/12/21/va-to-adopt-cdc-opioid-guidelines
9 Pat Anson, “Medicare Planning to Adopt CDC Opioid Guidelines,” Pain News Network, February 3, 2017, https://www.painnewsnetwork.org/stories/2017/2/3/medicare-planning-to-adopt-cdc-opioid-guidelines.
10 Pat Anson, “Pain Community Reacts to ‘Big Brother’ Medicare Policy,” Pain News Network, January 13, 2017, https://www.painnewsnetwork.org/stories/2017/1/13/pain-community-reacts-to-big-brother-medicare-policy.
Image Credit: CDC logo