A nonprofit division of Sevadar Foundation Inc.

For clinicians  ·  For facilities  ·  For families  ·  For staff

What the CDC said about the misapplication of its own guideline

A daily medication organizer with pills for different times, set against a green backdrop.

Written by

Dwaraa

in

The CDC did something unusual in 2022. It published a guideline that described, in its own text, how its previous guideline had been misapplied and what that misapplication cost patients.

The passage

From the 2022 Clinical Practice Guideline for Prescribing Opioids for Pain:

“Of particular concern, some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations. Such misapplication includes extension to patient populations not covered in the 2016 CDC Opioid Prescribing Guideline (e.g., cancer and palliative care patients), rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment, duration limits by insurers and pharmacies, and patient dismissal and abandonment. These actions are not consistent with the 2016 CDC Opioid Prescribing Guideline and have contributed to patient harm, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior.”

What changed as a result

  • Dosage thresholds were removed from the recommendation statements, deliberately, “to discourage the misapplication of opioid pain medication dosage thresholds as inflexible standards.”
  • Tapering recommendations were substantially expanded.
  • The recommendation on not stopping abruptly is explicit: “Unless there are indications of a life-threatening issue such as warning signs of impending overdose… opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.”
  • The guideline states its own status: it “should not be applied as inflexible standards of care” by health systems, pharmacies, payers, or any level of government.

Why this belongs on a long-term care site

Because the mechanism that produced the harm is not specific to opioids. It was a number applied to a population, without the individual entering the calculation, by people who had never met them. A nursing home pursuing a percentage reduction on any drug class is running the same mechanism, in a population less able to object.

The withdrawal evidence for antipsychotics illustrates the point precisely: most residents can come off safely, and a specific, identifiable minority — those who responded well to the drug, and those with more severe baseline symptoms — are likelier to relapse. A program chasing the number finds them the hard way, and their relapse does not appear in the measure.

Read more: Opioids in older adults · Measuring what changed.

References

  1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports. 2022;71(3):1–95. PMID 36327391 · DOI 10.15585/mmwr.rr7103a1.
  2. Agnoli A, Xing G, Tancredi DJ, Magnan E, Jerant A, Fenton JJ. Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids. JAMA. 2021;326(5):411–419. PMID 34342618 · DOI 10.1001/jama.2021.11013.
  3. Oliva EM, Bowe T, Manhapra A, et al. Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 2020;368:m283. PMID 32131996 · DOI 10.1136/bmj.m283.
  4. Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database of Systematic Reviews. 2018;3(3):CD007726. PMID 29605970 · DOI 10.1002/14651858.CD007726.pub3.

Bibliographic records in this note were retrieved from PubMed. Every reference links to its DOI or PubMed record.

Written and medically reviewed by Dr. Gurpreet Singh Padda, MD, MBA, MHP, founder and medical director of DWARAA. Last reviewed . This page is educational. DWARAA does not prescribe, deprescribe, diagnose or treat.

More posts