CDC Clarifies Opioid Prescribing Guideline

ATLANTA -- Clinicians who prescribe opioids to control chronic pain in cancer patients, palliative care, and end-of-life care should follow recommendations of clinical practice guidelines specific to the settings, according to the CDC.

Pain management in cancer, palliative care, and end-of-life care involves "unique therapeutic goals and balance of risks and benefits with opioid therapy," Deborah Dowell, MD, chief medical officer of the CDC National Center for Injury Prevention and Control, said in a letter to three national cancer organizations. Clinical practice guidelines specific to the settings should "guide treatment and reimbursement decisions regarding use of opioids as part of pain control in these circumstances."

The letter represented a clarification of the CDC's "Guideline for Prescribing Opioids for Chronic Pain" in response to comments from the American Society of Clinical Oncology (ASCO), National Comprehensive Cancer Network (NCCN), and American Society of Hematology (ASH). The three groups expressed concern that the CDC guideline might limit appropriate access to opioids for patients with chronic pain during cancer treatment, for cancer survivors with ongoing pain, and for patients with sickle cell disease.

Representatives of the three groups and the CDC met late last year to discuss existing guidelines for managing chronic pain and develop a strategy to resolve inconsistencies and improve communication.

"The guideline was developed to provide recommendations for primary care clinicians who prescribe opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care," Dowell said in the letter.

"The guideline is not intended to deny any patients who suffer from chronic pain from opioid therapy as an option for pain management. Rather, the guideline is intended to ensure that clinicians and patients consider all safe and effective treatment options for patients. Clinical decision-making should be based on the relationship between the clinician and patient, with an understanding of the patient's clinical situation, functioning, and life context, as well as careful consideration of the benefits and risk of all treatment options, including opioid therapy."

Dowell also referenced CDC resources for primary care providers, including information about assessing the benefits and harms of opioid therapy and an online training program for the CDC guideline. Additionally, she noted a National Heart, Lung, and Blood Institute expert panel report providing guidance for management of sickle cell disease.

In a joint statement, representatives of ASCO, NCCN, and ASH welcomed the clarification and expressed hope that it would facilitate access and reimbursement for patients with legitimate needs for opioid pain control.

"This clarification from [the] CDC is critically important because, while the agency's guideline clearly states that it is not intended to apply to patients during active cancer and sickle cell disease treatment, many payers have been inappropriately using it to make opioid coverage determinations for those exact populations," said ASCO Chief Executive Officer Clifford A. Hudis, MD.

ASH President Roy Silverstein, MD, pointed out that sickle cell disease causes "severe, chronic pain, which is debilitating on its own without the added burden of having to constantly appeal to the insurance companies every time a pain crisis hits and the initial request is denied."

NCCN CEO Robert Carlson, MD, stressed the importance of balancing the risks of inappropriate use of opioids with the desire to ensure that patients do not unnecessarily endure pain. "CDC's acknowledgement that clinical decision-making should be based on the relationship between physicians and their patients is important and in the best interest of people with cancer and sickle cell disease."

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