CHICAGO -- The American Medical Association (AMA) today urged advisers to the Centers for Disease Control and Prevention (CDC) Injury Center to recommend an overhaul of the CDC’s problematic guideline on opioid prescriptions that has proved devastating for patients with pain.

The AMA comments mirror those of the Opioid Workgroup, which was established for the purpose of reviewing draft revisions to the CDC’s 2016 guideline for prescribing opioids. The resulting Opioid Workgroup report outlines the foreseeable misapplication of the guidelines and points to more productive ways to move forward. The report was just presented to the Board of Scientific Counselors, which voted Friday to endorse it with few amendments.

The AMA is urging the CDC to remove arbitrary thresholds, restore balance and support comprehensive, compassionate care as it revises the guideline. In comments to the CDC Injury Center’s Board of Scientific Counselors, AMA Board of Trustees Chairman Bobby Mukkamala, M.D., pointed out that the opioid epidemic is becoming more lethal despite the CDC restrictive guideline due to illicitly manufactured fentanyl, fentanyl analogs, heroin, methamphetamine and cocaine. At the same time, patients are suffering from the undertreatment of pain and the stigma of having pain.

Mukkamala, who also is chair of the AMA task force focused on pain management and the drug overdose epidemic, wrote, “CDC’s threshold recommendations continue to be used against patients with pain to deny care. We know that this has harmed patients with cancer, sickle cell disease, and those in hospice. The restrictive policies also fail patients who are stable on long-term opioid therapy.”

States and insurers have turned the guideline into laws and unbending regulations, preventing physicians from treating patients as individuals with specific needs. The AMA outlined its concerns and recommendations last year in a letter to the CDC.

According to the CDC, it is anticipated that a revised guideline will be posted for public comment in late 2021.

The following are comments from Dr. Mukkamala:

On behalf of the physician and medical student members of the American Medical Association (AMA), I am writing to provide comments on the work of the Injury Center’s Board of Scientific Counselors to advise the Centers for Disease Control and Prevention (CDC) on the update to its 2016 Guideline for Prescribing Opioids.

A revised CDC Guideline that continues to focus only on opioid prescribing will perpetuate the fallacy that, by restricting access to opioid analgesics, the nation’s overdose and death epidemic will end. We saw the consequences of this mindset in the aftermath of the 2016 Guideline. Physicians have reduced opioid prescribing by more than 44 percent since 2012, but the drug overdose epidemic has gotten worse.

The opioid epidemic is now mostly fueled by illicitly manufactured fentanyl, fentanyl analogs, heroin, methamphetamine and cocaine.

As CDC heard from dozens of patients at the hearing, the 2016 Guideline is hurting patients. Patients with painful conditions need to be treated as individuals. They need access to multimodal therapies including restorative therapies, interventional procedures, and medications. These include non-opioid pain relievers, other agents, and opioid analgesics when appropriate.

Instead, patients with pain continue to suffer from the undertreatment of pain and the stigma of having pain. This is a direct result of the arbitrary thresholds on dose and quantity contained in the 2016 CDC Guideline. More than 35 states and many health insurers, pharmacies, and pharmacy benefit managers made the CDC’s 2016 arbitrary dose and quantity thresholds hard law and inflexible policy.

CDC’s threshold recommendations continue to be used against patients with pain to deny care. We know that this has harmed patients with cancer, sickle cell disease, and those in hospice. The restrictive policies also fail patients who are stable on long-term opioid therapy.

While the patient harm from the 2016 Guideline was unintended, it was not unforeseeable.

The AMA urges CDC to make all of the changes to the guideline that the AMA recommended in our June 2020 letter, much of which is also supported by Opioid Workgroup report and has been endorsed by the CDC Board of Scientific Counselors. Patients with pain need CDC to adopt the AMA and Opioid Workgroup recommendations to remove arbitrary thresholds, restore balance, and support comprehensive, compassionate, equitable care.

Patients with pain need the CDC to be their advocate and urge it to rescind the perceived limits on opioid therapy doses or days.

We have an opportunity here to care for these patients responsibly with your help. Thank you.