Which Guidelines are more Authoritative: CDC vs HHS?

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Which version of the CDC guidelines will you follow?

  • I'll stick with 2016 as most authoritative

    Votes: 1 20.0%
  • I'll use the updated and revised ones when they come out

    Votes: 4 80.0%
  • I'll use HHS or other guidelines.

    Votes: 0 0.0%

  • Total voters
    5

drusso

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CDC Guidelines:

CDC Guideline for Prescribing Opioids for Chronic Pain | Drug Overdose | CDC Injury Center

HHS Interagency Task Force Best Practice for Pain Management:

Reports

Also, there is now talk about revising and updating the CDC guidelines for 2020 with broader stakeholder input and less COI (both financial and ideological). If the guidelines are revised which version will you follow: 2016 or 2020?

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CDC Guidelines:

CDC Guideline for Prescribing Opioids for Chronic Pain | Drug Overdose | CDC Injury Center

HHS Interagency Task Force Best Practice for Pain Management:

Reports

Also, there is now talk about revising and updating the CDC guidelines for 2020 with broader stakeholder input and less COI (both financial and ideological). If the guidelines are revised which version will you follow: 2016 or 2020?

Follow unpublished guidelines that have not ben submitted for public comment?
 
CDC Guidelines:

CDC Guideline for Prescribing Opioids for Chronic Pain | Drug Overdose | CDC Injury Center

HHS Interagency Task Force Best Practice for Pain Management:

Reports

Also, there is now talk about revising and updating the CDC guidelines for 2020 with broader stakeholder input and less COI (both financial and ideological). If the guidelines are revised which version will you follow: 2016 or 2020?
What does the HHS document say about MEDs?
Are they on board with the CDC's 90 MED non-limit limit, or do they suggest something else?

As far as which I'll follow, 2016 or 2020, I suppose we'll be best advised to follow the most recent one, regardless of how good it is. I'm of the mindset that if it comes from the crew that grants us the privilege to have our livelihood and has the ability to destroy it all in one action (Fed/State governments) then we'd be stupid to ignore their most current recommendations, regardless of how much we agree with them or not. It is the gazelle that strays from the herd, that becomes lunch for the lions.
 
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Follow unpublished guidelines that have not ben submitted for public comment?

Many people were early adopters to the 2016 CDC guidelines before they were vetted and approved and despite the concerns raised in those guidelines public comment session. I suspect that people will be true for HHS.

In a free market of ideas, multiple competing guidelines allow for the best one to emerge.
 
Many people were early adopters to the 2016 CDC guidelines before they were vetted and approved and despite the concerns raised in those guidelines public comment session. I suspect that people will be true for HHS.

In a free market of ideas, multiple competing guidelines allow for the best one to emerge.

Ideas are different than laws and different than guidelines.

Best is different when measured by different yardsticks and agendas.
 
no comment on max MED.

fwiw, follow the one the DEA is going to follow - and as of right now, that is the 2016 CDC.
 
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What does the HHS document say about MEDs?
Are they on board with the CDC's 90 MED non-limit limit, or do they suggest something else?

As far as which I'll follow, 2016 or 2020, I suppose we'll be best advised to follow the most recent one, regardless of how good it is. I'm of the mindset that if it comes from the crew that grants us the privilege to have our livelihood and has the ability to destroy it all in one action (Fed/State governments) then we'd be stupid to ignore their most current recommendations, regardless of how much we agree with them or not. It is the gazelle that strays from the herd, that becomes lunch for the lions.
From the draft:

The idea of a ceiling dose of opioids has been put forward, but establishing such a ceiling is difficult, and the precise level for such a ceiling has not been established.107 The risk of overdose increases with the dose, but the therapeutic window is highly variable. For example, the CDC guideline identified a dose limit of 90 morphine milligram equivalents (MMEs) per day. More recent data evaluated the risk of death related to opioid dose in 2.2 million North Carolinians and found that the overall death rate was only 0.022% per year.108
 
Overdose rates and addiction seem to be all that is focused on but what about the fact that opioids don’t help chronic pain. That’s the point I continuously hammer home to docs in town
 
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J Pain. 2018 Dec 28. pii: S1526-5900(18)31053-8. doi: 10.1016/j.jpain.2018.12.007. [Epub ahead of print]
Effectiveness of opioids for chronic noncancer pain: a two-year multicenter, prospective cohort study with propensity score matching.
Veiga DR1, Monteiro-Soares M2, Mendonça L3, Sampaio R4, Castro-Lopes JM5, Azevedo LF6.
Author information

Abstract
Opioid use in CNCP is still controversial regarding their effectiveness and safety. We conducted a 2-year prospective cohort study in 4 multidisciplinary chronic pain clinics (MCPCs) to assess long-term opioid effectiveness in CNCP patients. All adult CNCP patients consecutively admitted to their first consultation were recruited. Demographic and clinical data were collected, and propensity score matching was used to adjust for differences between opioid users and nonusers. The Brief Pain Inventory (BPI) and the Short version of Treatment Outcomes in Pain Survey (S-TOPS) were used to measure pain outcomes and quality of life. A total of 529 subjects were matched and included in our analysis. Rate of prescription opioid use was 59.7% at baseline, which increased to 70.3% over 2 years, of which 42.7% of the prescriptions were for strong opioids. Opioid users reported no improvement regarding pain symptoms, physical function, emotional function and social/familiar disability. Opioid users reported higher satisfaction with care and outcomes at 1 year of follow-up, but at 2 years, they only reported improvement in satisfaction with outcomes. Opioids have shown limited effectiveness in long-term CNCP management, as opioid users presented no improvements regarding functional outcomes and quality of life. These findings emphasize the need for proper selection and outcome assessment of CNCP patients prescribed opioids. PERSPECTIVE: This study adds important additional evidence concerning the controversial use of opioids in CNCP management. Opioid users presented no improvement regarding pain relief, functional outcomes and quality of life over 2 years of follow-up. Therefore, our results support and highlight the limited effectiveness of opioids in long-term CNCP management.
 
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Pain Med. 2018 Dec 26. doi: 10.1093/pm/pny275. [Epub ahead of print]
A Two-Year Prospective Multicenter Study of Opioid Therapy for Chronic Noncancer Pain: Prescription Trends and Predictors.
Veiga DR1, Mendonça L2, Sampaio R3,4,5,6, Castro-Lopes JM2,3,4,5, Azevedo LF2,7,8.
Author information

Abstract
OBJECTIVES:
Opioid use in chronic pain has increased worldwide in recent years. The aims of this study were to describe the trends and patterns of opioid therapy over two years of follow-up in a cohort of chronic noncancer pain (CNCP) patients and to assess predictors of long-term opioid use and clinical outcomes.

METHODS:
A prospective cohort study with two years of follow-up was undertaken in four multidisciplinary chronic pain clinics. Demographic data, pain characteristics, and opioid prescriptions were recorded at baseline, three, six, 12, and 24 months.

RESULTS:
Six hundred seventy-four CNCP patients were recruited. The prevalence of opioid prescriptions at baseline was 59.6% (N = 402), and 13% (N = 86) were strong opioid prescriptions. At 24 months, opioid prescription prevalence was as high as 74.3% (N = 501), and strong opioid prescription was 31% (N = 207). Most opioid users (71%, N = 479) maintained their prescription during the two years of follow-up. Our opioid discontinuation was very low (1%, N = 5). Opioid users reported higher severity and interference pain scores, both at baseline and after two years of follow-up. Opioid use was independently associated with continuous pain, pain location in the lower limbs, and higher paininterference scores.

CONCLUSIONS:
This study describes a pattern of increasing opioid prescription in chronic pain patients. Despite the limited improvement of clinical outcomes, most patients keep their long-term opioid prescriptions. Our results underscore the need for changes in clinical practice and further research into the effectiveness and safety of chronic opioid therapy for CNPC.
 
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Pain Med. 2018 Sep 3. doi: 10.1093/pm/pny169. [Epub ahead of print]
Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care.
Chuang E1, Gil EN1, Gao Q2, Kligler B3, McKee MD1.
Author information

Abstract
OBJECTIVE:
The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population.

DESIGN:
This is a cross-sectional observational study.

SETTING:
Subjects were recruited from six urban primary care health centers.

SUBJECTS:
Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included.

METHODS:
Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment.

RESULTS:
Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics.

CONCLUSIONS:
This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.
 
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Pain. 2018 Oct;159(10):2097-2104. doi: 10.1097/j.pain.0000000000001315.
Changes in pain intensity after discontinuation of long-term opioid therapy for chronic noncancer pain.
McPherson S1,2,3, Lederhos Smith C1,2, Dobscha SK4,5, Morasco BJ4,5, Demidenko MI4, Meath THA4,6, Lovejoy TI4,5,7.
Author information

Abstract
Little is known about changes in pain intensity that may occur after discontinuation of long-term opioid therapy (LTOT). The objective of this study was to characterize pain intensity after opioid discontinuation over 12 months. This retrospective U.S. Department of Veterans Affairs (VA) administrative data study identified N = 551 patients nationally who discontinued LTOT. Data over 24 months (12 months before and after discontinuation) were abstracted from VA administrative records. Random-effects regression analyses examined changes in 0 to 10 painnumeric rating scale scores over time, whereas growth mixture models delineated pain trajectory subgroups. Mean estimated pain at the time of opioid discontinuation was 4.9. Changes in pain after discontinuation were characterized by slight but statistically nonsignificant declines in pain intensity over 12 months after discontinuation (B = -0.20, P = 0.14). Follow-up growth mixture models identified 4 pain trajectory classes characterized by the following postdiscontinuation pain levels: no pain (average pain at discontinuation = 0.37), mild clinically significant pain(average pain = 3.90), moderate clinically significant pain (average pain = 6.33), and severe clinically significant pain (average pain = 8.23). Similar to the overall sample, pain trajectories in each of the 4 classes were characterized by slight reductions in pain over time, with patients in the mild and moderate pain trajectory categories experiencing the greatest pain reductions after discontinuation (B = -0.11, P = 0.05 and B = -0.11, P = 0.04, respectively). Pain intensity after discontinuation of LTOT does not, on average, worsen for patients and may slightly improve, particularly for patients with mild-to-moderate pain at the time of discontinuation. Clinicians should consider these findings when discussing risks of opioid therapy and potential benefits of opioid taper with patients
 
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Pain Med. 2018 Sep 3. doi: 10.1093/pm/pny169. [Epub ahead of print]
Relationship Between Opioid Analgesic Prescription and Unemployment in Patients Seeking Acupuncture for Chronic Pain in Urban Primary Care.
Chuang E1, Gil EN1, Gao Q2, Kligler B3, McKee MD1.
Author information

Abstract
OBJECTIVE:
The widespread use of opioid analgesics to treat chronic nonmalignant pain has contributed to the ongoing epidemic of opioid-related morbidity and mortality. Previous studies have also demonstrated a relationship between opioid analgesic use and unemployment due to disability. These studies have been limited to mainly white European and North American populations. The objective of this study is to explore the relationship between opioid analgesic use for chronic nonmalignant pain in an urban, mainly black and Hispanic, low-income population.

DESIGN:
This is a cross-sectional observational study.

SETTING:
Subjects were recruited from six urban primary care health centers.

SUBJECTS:
Adults with chronic neck, back, or osteoarthritis pain participating in an acupuncture trial were included.

METHODS:
Survey data were collected as a part of the Acupuncture Approaches to Decrease Disparities in Pain Treatment two-arm (AADDOPT-2) comparative effectiveness trial. Participants completed a baseline survey including employment status, opioid analgesic use, the Brief Pain Inventory, the global Patient Reported Outcomes Measurement Information Systems quality of life measure, the Patient Health Questionnaire-9 (PHQ-9), and demographic information. A multivariable logistic regression model was built to examine the association between opioid analgesic use and unemployment.

RESULTS:
Opioid analgesic use was associated with three times the odds of unemployment due to disability while controlling for potential confounders, including depression, pain severity, pain interference, global physical and mental functioning, and demographic characteristics.

CONCLUSIONS:
This study adds to the growing body of evidence that opioid analgesics should be used with caution in chronic nonmalignant pain.
For the current and future PM physicians out there such as myself, we should have a thread where we continue to compile evidence for/against COT to keep the most up to date for our practice. I know the “opioid epidemic in a nutshell”is good, but one ongoing thread regarding evidence on this topic would be very beneficial in getting everyone on the same page.
 
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