Transcript for Telebriefing: Updated Clinical Practice Guidelines for Prescribing Opioids for Pain
Wednesday, November 9, 2022
Please Note: This transcript is not edited and may contain errors.
Welcome, everyone to today’s conference call at this time your lines have been placed on listen only for today’s conference until the question and answer portion of our call, at which time you will be prompted to press star one on your touchtone phone. Please ensure that your line is unmuted and please record your name when prompted, so that I may introduce you to ask your question. We do ask that you limit yourself to one question and one follow up to give everyone time to get through with your questions. Our conference is being recorded and if you have any objections, you may disconnect at this time. I went out to recover to return our host, Mr. Benjamin Haynes. Sir, you may proceed.
Thank you, Jill. And thank you all for joining us today as we released the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain. We’re joined by Dr. Christopher Jones, Acting Director for the National Center for Injury Prevention and Control and the co-author of the 2022 clinical practice guideline. Dr. Jones will discuss the guideline and we’ll respond to your questions after his remarks. This briefing is embargoed until 1pm when the 2022 clinical practice guideline will be live on CDC MMWR website will now turn the call over to Dr. Jones.
Thank you, Ben. And good afternoon to everyone. Thank you for joining us today to discuss this important topic. Pain affects the lives of millions of Americans and improving care for those living with pain is a public health imperative. To advance pain care in the US, CDC is releasing new recommendations for clinicians who provide pain care for adults with short and long term pain which can include prescribing opioids. The recommendations released today update and replace the guidelines CDC released in 2016. The new 2022 clinical practice guideline aims to help clinicians work with their patients to provide the safest and most effective pain care possible. The science on pain and pain care has advanced over the past six years since the 2016 guideline was released. We’ve learned more from new research and importantly, we’ve had opportunities to listen to learn from and collaborate with people living with pain, their caregivers and their clinicians. We heard time and again that all types of pain need to be appropriately assessed and treated. Whether or not prescription opioids are part of the treatment plan. And we saw the critical importance of having clinical recommendations that support flexible, tailored, patient centered care rather than a one size fits all approach. We understand that patients and their providers need better tools so they can work together toward effective pain care. It’s against this backdrop that we’ve updated and expanded our recommendations into 2022 guideline. Taking into account new science and data along with lessons learned about the challenges patients and providers face when managing pain and pain care. The new 2022 guideline is a clinical tool to empower patients and clinicians to make informed decisions together.
I want to emphasize a few important points about the new guideline. First, these recommendations should support not replace care that is tailored to an individual patient’s needs, and health history. Second, the guideline recommendations are voluntary and meant to assist and guide shared decision making between a clinician and patient. The guideline should not be used as a rigid standard of care or inflexible policy or law. It’s not meant to be implemented as absolute limits of policy or practice by clinicians, health systems, insurance companies or governmental entities. The guideline provides information about a full range of options for pain management and encourages clinicians to work with other professionals to provide the best evidence-based pain care possible. It’s also important to note that the guideline does not apply to pain management related to sickle cell disease, cancer related pain treatment, palliative care or end of life care. Other clinical practice guidelines have been developed by professional societies to guide pain care decisions for these conditions.
At CDC, we care deeply about the health, safety and quality of life of patients living with pain, and are committed to ensuring that patients get the best possible treatment. In my work as a pharmacist, and in my own personal life, I’ve seen the profound impacts pain can have on someone’s life. And I’ve also seen how that life can be transformed when a patient is able to access safe and effective care. That’s why the release of the 2022 guideline is so important. It’s intended to help improve communication between clinicians and patients and to support the patient clinician relationship. Clinicians will be able to use this guideline to help patients set and achieve personal goals to reduce their pain and improve their function and quality of life. We know that people who live with pain experience many challenges. Having safe, consistent and effective pain treatment should not be one of them.
As we release the new 2022 clinical practice guideline today, I want to give you a high level, well summary of the guideline and its recommendations. The guideline addresses four key aspects of pain management and opioid prescribing, which include deciding whether to initiate opioids for pain, selecting opioids and determining dosages, deciding duration of the initial prescription and conducting follow up and assessing risk and addressing potential harms. The guideline features several major updates reflecting the expanded scope of the available scientific evidence, while the 2016 guideline focused almost exclusively on chronic pain,the guideline released today also includes recommendations for treating acute and subacute pain. We define chronic pain is pain that lasts more than three months, such as pain that accompanies an ongoing health condition like arthritis. Acute pain is defined as pain that lasts less than a month, like the pain following a minor surgery or broken bone. And subacute pain falls in the middle. It’s pain that lasts longer than acute pain, but it’s not yet considered chronic. It’s particularly important that the guideline address this type of pain, as research shows that long term opioid therapy often is initiated during the subacute timeframe.
Recommendations in the new guideline had been expanded from the focus on clinicians providing care to adults in the primary care setting to a broader range of providers in more diverse outpatient settings such as surgeons, oral health practitioners, and emergency medicine clinicians. New scientific information is also included on the use of non-opioid medications and non-medication treatments for different types of pain. We’ve also expanded the evidence base around the use of opioid pain medications and other pain treatments in certain groups, like older adults and pregnant people, and in people with conditions posing special risks, such as those with a history of substance use disorder. Another critical addition of the 2022 guideline is the incorporation of new guidance to help clinicians and patients carefully weigh both the benefits and risks of tapering opioids are continuing them. Practical tips on how to taper in an individualized patient centered manner have been added to help clinicians if the decision is made to taper opioids. And the guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids.
In addition to new evidence, we’ve added structural elements that make it very clear that the guideline is a clinical tool to support individualized care and should not be used as an inflexible standard of care or rigid policy or law. To emphasize flexibility and encourage individualized care in using the new guideline, we’ve highlighted overarching principles of safe and effective pain treatment rather than focusing on specific dosage thresholds. We also specify which recommendations apply to patients who are being considered for initial treatment with prescription opioids, versus those that have already been receiving opioids as part of ongoing care, a key update to the 2022 guideline. We hope these important updates and changes will provide the tools necessary for clinicians to draw on their own empathy to support their patients, while using the principle of shared decision making to make choices about pain care. CDC encourages clinicians to create and update pain treatment plans with their patients, based on the patient’s individual needs and circumstances.
CDC’s mission is to protect the health and lives of all Americans and all patients with pain should have access to effective safe and sustainable pain treatment options. Yet time and time again, research shows that where you live, what means you have and who you are, can result in far less access to evidence-based pain care. For example, black patients are less likely to be referred to a pain specialist and receive prescription opioids at lower doses than white patients. However, safeguards on opioid prescribing are disproportionately applied to black patients. So to highlight and help address these issues, we have focused on health equity and disparities related to pain care throughout the new guideline.
This critical edition prioritizes, making safe and effective pain treatment more equitable for all patients. Drafting of the updated guideline was a joint effort, and I want to thank our partners and collaborators in the process. CDC obtained input on the draft guideline through feedback from individual conversations with patients, caregivers and clinicians, as well as from thousands of comments during public comment opportunities. CDC also sought input from a federally chartered Advisory Committee, federal partners and peer reviewers with scientific and clinical expertise. We sincerely appreciate the collaborative efforts and thoughtful feedback provided throughout the clinical practice guideline update process.
I especially want to thank those individuals who share their personal experiences, about how pain impacts their lives, and the challenges they continue to face in obtaining pain care, including obtaining opioids. Pain and pain care remain a problem for millions of Americans and there is much work to be done to advance equitable pain treatment in our country. CDC is committed to continuing to work with clinical partners and patient organizations to improve pain care by giving patients and clinicians the data, tools, and guidance they need to make informed, individualized, and patient-centered treatment decisions. Our hope is that this new guideline informed by the latest science and what we’ve learned about the human story of patients living with pain can be a tool to help clinicians ensure the safest and most effective treatment for their patients as provided, and that pain function and quality of life will improve for the millions of Americans dealing with pain each day. Thank you and I look forward to your questions and I’ll turn it back over to Ben.
Thank you, Dr. Jones. Jill, I believe we are ready to take questions.
Thank you at this time, if you would like to ask a question, please press star one on your touch tone phone. Please ensure that your line is unmuted please record your name when prompted. So that I may introduce you to ask your question. As reminder, we’re asking that you ask only one question and one follow up to allow everyone to ask a question that’s in the queue. Please stand by for our first question. Our first question is from Andrew Joseph with Stat. Your line is open.
Hi, thanks very much. Um, so CDC has been saying basically since at least 2019, that the 2016 guidelines were misapplied. And I know in your commentary in the New England Journal, you kind of make the point that you’re gonna monitor for unintended effects going forward. But what does that actually look like? Like what happens if an insurer still has a cap of 90 mme, or even an individual physician is, you know, cutting patients off, like what is CDC going to do about that?
Thanks for the question. I think it’s a really important point. And certainly, we have tried throughout the guideline to put elements in place with really the overarching principle about supporting clinical judgment in individualized patient centered care. So, I want to be very clear, with this conference calland with the release of the guideline today, that if policies are put in place that have one size fits all rigid standards of care that is inconsistent with the goals and intent of this guideline as a clinical tool to inform decision making, I think operationally, if we see practices like that that are occurring. First, we see it as an educational opportunity. Certainly, if people are purporting to derive from the guideline that that’s the justification for taking some rigid action that applies to all patients. So, we would see that as an educational opportunity. And we’ll be monitoring and engaging with, as I mentioned, clinical partners and patient organizations to also raise awareness for where those circumstances may occur, isn’t engaging as appropriately to share accurate information about the latest science and about the intent of the guideline. Next question, please.
Thank you. Our next question is from Judy Bauman with Bloomberg Law, your line is open.
Hi, thanks for taking my question. I’m wondering how you see the guidelines fitting into you know what’s happening now, with the opioid epidemic, just given how much of the trajectory has changed since the 2016 guidelines come out? I know that you said you updated it with the science, but I’m wondering how you see the new recommendations fitting in with the current crisis?
Sure, thank you. I think, you know, the really important point here is that the release of the guideline today is about advancing pain care. We know that at least one in five people in the country have chronic pain and is one of the most common reasons why people present to their health care provider. And the goal here is to advance pain, function and quality of life for that patient population, while also reducing misuse, diversion consequences of prescription opioid misuse. But I want to be very clear that actions related to the current state of the overdose crisis, which are very much driven by illicit synthetic opioids like illicitly made fentanyl, resurgent methamphetamine are not the aim of this guideline today. That work is happening across the government as a whole of government approach, including work from CDC to support our state and local partners to expand access to naloxone, link people to treatment for opioid use disorder, advance harm reduction efforts and focus on upstream prevention to reduce initiation of substance use in the first place. So I don’t think it’s an either or I think we can pursue both of those at the same time. But today’s announcement is really about improving the lives of patients living with pain. Thank you.
Next question, please.
Thank you. Our next question from Pien Huang with NPR. Your line is open.
Hi, thanks for taking my question. I have a follow up to the first question about the 2016 guidelines being misapplied. And understand that like guidance is voluntary that there’s an educational component but how is this going to make an impact when there’s a lot of power? Will season even laws in place that make doctors fearful of prescribing?
Well, I hope that it will spur a conversation for reassessment of here’s the latest science distilled down into a document that can help guide patient centered care. I also hope that the safeguards that we’ve tried to put in place about the intent and purpose of this guideline can also foster awareness and opportunities to engage with a range of clinical health systems and other partners to say, where are we with pain care? What are those barriers that still exist? We so importantly, heard from the patient community, from advocates for patients living with pain, that there are many challenges at multiple levels in their day to day in managing pain. And our hope is that this guideline provides a roadmap for how we can change that for those patients.
One quick follow up, are you working with other federal agencies to sort of make that happen?
Yes, as I mentioned, in my opening remarks, this has absolutely been a collaborative effort with our federal partners, including CMS, FDA, NIH, and others. And so we have engaged them throughout the process. We have been working with our partners at CMS, they issued a payment rule earlier this week, that I think syncs up nicely with the idea of being able to support comprehensive multidisciplinary pain care in the range of pain treatment options. So we believe that that engagement with federal partners is really important. We have ongoing engagement with DEA and others as well in the law enforcement space to help work through what is appropriate pain care, how are we working to address our shared missions of reducing harms related to opioid misuse and diversion, while also safeguarding access for patients who have a clinical need for receiving opioids.
Next question, please.
Thank you. Our next question is from Sandhya Raman with CQ Roll Call, your line is open.
Hi, thanks for doing the call.
I was curious if you could talk a little bit about how some of these guidelines would work in conjunction with you know, dispensing naloxone or if someone has chronic pain of some sort. But that needs to be addressed that might be on medication assisted treatment, and might use like a non opioid option.
Thanks for raising the question. In the guideline, especially in the latter recommendations, we focus on mitigating potential harms if patients are receiving opioids. And one of the shifts that we’ve made from when this draft came out in February to the final draft, or the final version released today, is that we recognize that opioids, prescription opioids when they’re prescribed do carry a risk, they carry a risk for overdose and that risk is certainly higher when people are receiving higher doses of opioids, or they’re receiving opioids in combination with benzodiazepines. But we also heard from our peer reviewers and from public comment, that really, naloxone is a mitigation intervention that could be useful for all patients receiving opioids. So you’ll notice in the guideline in those latter recommendations we do call for if patients are receiving opioids in particular longer term opioids for chronic pain that naloxone be offered to them. Certainly, there’s other guidance from HHS from professional societies like ASAM, about the management of patients with opioid use disorder. Our guideline clearly states that if opioid use disorder is detected in a patient, patients should be provided or referred to evidence-based medications for opioid use disorder treatment. And certainly, naloxone would be a part of complimentary treatment for that population, which is, you know, well documented, increased risk for overdose. So we see this as complementary to efforts to expand naloxone access, both to patients who are receiving opioids for pain, but also to patients who have other risks for overdose like opioid use disorder.
Next question, please.
Before we take our next question, I just like to add a reminder, please press star one. If you would like to ask your question. Please record your name to be introduced. Once again, it is star one. Our questions from Tom Howell with the Washington Times Your line is open.
Hi, thanks for doing the call. I wanted to know if you could talk about the recommendation against rapid tapering off of opioids. You’d highlighted that in your opening. Specifically, I was wondering, is there a risk if people are cut off too soon that they might seek out their own opioids in the illicit market, that kind of thing? Can you speak to just the interplay between those two things why it’s so important not to taper off too quickly. Thank you.
Thanks for very important question. I think, as I mentioned, really the focus and expansion of information around how to approach tapering opioids. And certainly advising against abrupt discontinuation or rapid dosage reductions is a key addition to the 2022 guideline. And that is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered. And we have seen that play out certainly in the research and also from personal stories from patients whose clinicians stop prescribing to them or abandon them from care or rapidly forced them to get too much lower doses of opioids. And there are very real harms. We tried to highlight that in the guideline. So things like mental health crises, suicidal ideation or behavior, psychological distress, and potentially even for some people seeking out opioids through other markets, like illicit markets in order to stave off withdrawal, or to supplement if they are at too low of a dose. So it is a very real risk, and one that we wanted to make sure that we highlighted when patients and providers are thinking about both the benefits and risk of long term opioid therapy.
Jill, I believe we have time for one more question.
Thank you to come from Michelle Benitez with Univision, your line is open.
Hi, thank you so much. Okay, so you mentioned that minorities, I don’t like this or didn’t use prescription in different ways. And Hispanics are one of the fastest growing minority populations and languished in the ever we’re the new guidance and recommendations to explain the use of opioids for the Hispanic community. So you think they should have some type of help or guidelines in Spanish for these patients?
Thanks for raising the question and raising the issue of equity. As I mentioned, we’ve tried to infuse principles around equity and disparities in pain care, in particular around communities of color throughout the guideline. As we are embarking on release of the guideline today, there will be a series of ancillary resources, fact sheets, toolkits, other items that are developed both for clinicians and patients, and advancing equitable access to pain care for all patients will be a part of that. I think thinking about populations where you know, taking into account cultural language barriers, other aspects of pain care will be important as we continue to develop those resources.
Thank you, Dr. Jones. And thank you all for joining us this afternoon. If you have further questions, please call the main media line at 404-639-3286 where you can email firstname.lastname@example.org Thank you.
This does conclude today’s conference call. We thank you all for participating You may now disconnect and have a great rest of your day.
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