CDC 2022 Opioid Prescribing Guideline: Tapering

https://www.practicalpainmanagement.com/resources/clinical-practice-guidelines/cdc-2022-opioid-prescribing-guideline-tapering

Guideline Analysis: A look at the updated recommendations regarding the opioid tapering process and MME cutoffs.

In this analysis, we break down the various aspects of the proposed revisions to the CDC Guideline on Opioid Prescribing for Chronic Pain to help clinicians, patients, and caretakers alike understand their nuances and to provide expert review of their applicability, potential benefits, and potential concerns. Specifically, we examine an integral part of the 2016 original and 2022 revised guidelines: recommendations on opioid tapering.

Opioid tapering has historically been, and continues to be, one of the most controversial aspects of the original 2016 CDC prescribing guideline, and, thus, has become a crucial topic to examine in the proposed 2022 guidelines (expected to be finalized and released by the end of this year).

The concept of tapering does not exclusively apply to opioids, as it describes the general process of lowering any amount of medication in a gradual way to avoid potential precipitation of withdrawal and to ensure that a patient’s condition does not worsen without said medication. However, with opioids in particular, inappropriate reasons to taper or the use of an inappropriate tapering process can be associated with detrimental cognitive, physical, and emotional issues, all of which should be avoided when possible.

Prior to making the decision to taper an opioid, it is essential to establish an appropriate reason to taper in the first place. There could be several clinical reasons for initiating a taper:

• lack of efficacy
• attempt at opioid rotation
• development of adverse events
• abhorrent use/misuse

MME Limits

Each of the reasons to taper noted above are specifically noted in the 2016 CDC Guideline on Prescribing Opioids for Chronic Pain,¹ however, to the dismay of several expert clinicians, researchers, organizations, and stakeholders,²⁻⁵ the recommendation seemed to emphasize achieving a dosing threshold of 90 morphine milligram equivalents (MME) or lower per day. In addition, the 2016 recommendation advised to “consider tapering opioids to a lower dosage or to taper and discontinue opioids” if the patient is at ≥ 90 MME/day.

While the authors of the CDC guideline did not outright recommend blind and blanket tapering for those on opioids at ≥ 90 MME/day, unfortunately, because of the framing of the recommendations, several states enacted legislation while third-party payers created policies revolving around cutoffs utilizing the 90 MME/day threshold.¹˒⁶ These regulations resulted in blind tapering, reductions, and, in some cases, abrupt discontinuation of opioids across many patient populations who had been maintained on stable opioid therapy.²⁻⁸

Tapering Process

Regarding the process of how to taper, the 2016 guidelines were more vague, although their recommendations were more in line with the literature and best practice of the time.⁹ The CDC guideline authors did note that clinicians should collaborate with the patient on a tapering plan and that, if the patient agreed to taper, and that taper should remain slow, gradual, and even require pauses to allow for “gradual accommodation.”¹

They also recommended patients be monitored closely for anxiety, among other symptoms that may result from a taper.¹

Regarding the pending update to the CDC opioid prescribing guideline, there seems to be a greater emphasis by not only the authors but also by relevant stakeholders and the review panel, on gradual, patient-centered tapers.¹⁰

MME Limits

Despite what the authors indicate regarding MME/day cutoffs, there is a section in the draft update that discusses the plateauing of analgesia at opioid dosing of around 50 MME/day based on evidence with a level of “type 2” quality.¹⁰ While there is no mention of using 50 MME/day as a new dosing cutoff, the inclusion of 50 MME/day to describe evidence of efficacy is concerning, to say the least.

Tapering Process

There has been no significant change in recommendations for appropriate reasons to taper.¹⁰ Additionally, similar to the 2016 guideline, the 2022 draft update recommends a vague but gradual approach to opioid tapering, recommending specifically against blanket tapers or abrupt discontinuation.¹⁰ The authors of the updated document (who, of note, are the same authors of the 2016 guideline aside from one new contributor) also make a specific note, highlighted in the summary, that the guidelines are not “a law, regulation, and/or policy that dictates clinical practice or [serves as] a substitute for FDA-approved labeling.” This distinction is especially important to consider given that more than 170 policy changes made between 2016 and 2018 related to opioid-dosing cutoffs and MME/day thresholds, many of which were directly in response to the 2016 guidelines.⁶˒¹⁰

In fact, the 2022 draft update confirms the misapplication of the 2016 recommendations (specifically with regard to policies) concerning “opioid tapers and abrupt discontinuation without collaboration with patients; rigid application of opioid dosage thresholds.”¹⁰ The 2022 authors agree, as they did in a 2019 article published in the New England Journal of Medicine,⁷ that misapplying these recommendations in particular may have contributed to physical and psychological patient harm, undertreated pain, withdrawal symptoms, and suicidal ideation and behavior.¹⁰ They indeed recommend against the strict utilization of dosing thresholds based off of MME/day cutoffs.¹⁰

Like other revisions to the new guidelines, it does appear that the CDC has attempted to clarify and highlight important concerns that arose after the vast implementation of their 2016 opioid prescribing guidelines around opioid tapering. We commend the CDC for confirming the appropriate reasons to taper, for emphasizing patient-centered decisions regarding tapering, and for emphasizing that tapers be enacted with a gradual and careful approach.

However, there has not been a consensus update by pain management specialists based on clinical trials or sound scientific data regarding specific tapering recommendations such as duration, reduction amount, or frequency of reduction, and, thus, there remains significant discomfort and disparity among clinicians regarding how to adequately taper a patient off of opioids.¹¹˒¹²

Further, as noted, the CDC’s discussion that “type 2” evidence does not support dosing of opioids greater than 50 MME/day because of lack of association with significant efficacy and increased risk of adverse events when used in chronic pain.¹⁰ While the CDC recommends against the use of rigid dosing cutoffs, the language around their concerns with doses greater than 50 MME/day reads similar to the language used in 2016 guideline on 90 MME/day. The latter was a major reason cited by providers for tapering stable patients off opioids.¹¹ To reduce these concerns, it would be prudent for the CDC to specifically recommend against the use of 50 MME/day as a potential dosing cutoff going forward.

Overall, opioid tapering continues to be a difficult therapeutic aspect entwined within the use of opioids, not only because of the difficulties in identifying appropriate reasons/individuals to taper, but then to develop a tapering strategy with the patient. The CDC’s draft update to the opioid prescribing guideline attempts to provide some clarity on all of these aspects, however, remains vague in tapering strategies and allows for ambiguity around potential tapering in individuals on certain opioid doses.

No matter the final language, the authors believe it is pertinent that opioid tapering occurs in only appropriate situations, where patient physical and psychological harm is minimized, and where the tapering process remains individualized.

Filed under: General Problems