Greater Decline in Opioid Prescribing After
CDC Guidelines Released
by Judy Butler
What happens when a government agency uses an unbiased, evidence-based approach to examine opioids for chronic pain? It finds no evidence of long-term benefits and extensive evidence of possible harms of opioids, recommends nonpharmacological and nonopioid pharmacological therapy for treatment of chronic pain, withstands an industry-funded assault, and reduces opioid prescribing.
That, in a nutshell, is the story of CDC’s Guideline for Prescribing Opioids for Chronic Pain, released in March 2016.
The Centers for Disease Control and Prevention (CDC), did not include any industry-funded participants in the process of drafting its guidelines. This stands in contrast to other federally-funded efforts addressing chronic pain and opioids: the National Institutes of Health, the Food and Drug Administration, and the Institute of Medicine all included industry-funded participants in their efforts.
It’s no surprise that the draft CDC guideline was met unfavorably by the opioid industry, which remained behind the scenes. Working through surrogates with undisclosed funding, the industry mobilized forces against the publication of the guidelines. As reported by the Associated Press, many of those attacking the CDC guideline belong to the Pain Care Forum (PCF), a group founded by the chief lobbyist of OxyContin-maker Purdue Pharma and comprised primarily of drugmaker-funded members. For example, a letter from the Washington Legal Foundation (WLF) argued that the CDC broke the law by not disclosing its advisers’ identities and should redo the guidelines. Ironically, the WLF did not disclose that it received funds from Purdue.
The American Academy of Pain Management (now the Academy of Integrative Pain Management), another Purdue-funded PCF member, called for Congress to investigate the CDC. Pain patients mobilized to oppose the guidelines included representatives from the Interstitial Cystitis Association and other consumer advocacy group members of PCF, and also Purdue-funded groups including the Power of Pain Foundation (now iPain).
Although the CDC opened the guideline for comments and delayed its release to maximize public participation, the opioid industry failed to invalidate its conclusions. The CDC compiled and responded to all the comments derived from a constituent webinar and public comment, and stood behind the strength of its evidence-based guideline. The CDC's steadfastness paid off in public health benefits.
A recent study in the Annals of Internal Medicine demonstrates the substantial impact of the guideline on opioid prescribing rates. The study compared monthly opioid prescribing data prior to guideline release (January 2012 - February 2016) to post release (March 2016 - December 2017). The monthly drop in overall opioid prescribing rates increased from 23.48 per 100,000 to 56.74 per 100,000. For prescriptions higher than the upper limit of 90 morphine milligram equivalents (MME) per day recommended by the CDC, the monthly decline increased from 3.56 per 100,000 persons to 8 per 100,000.
The CDC guideline has also played an interesting role in opioid litigation. As part of a 2017 settlement with Santa Clara County, California, Pfizer agreed not to make any claims that conflicted with the CDC guideline nor support organizations and individuals that make such claims. Pain News Network (PNN) reported it will no longer receive Pfizer’s $10,000 annual grant for sponsorship of its newsletter. However, it’s unlikely that other opioid manufacturers would take similar steps, unless required to by litigation.
This is a success story that we should recognize and encourage. One can only imagine the impact that the federal government could have on opioid prescribing—and rational prescribing of other drugs—if all Federal actions had more evidence and fewer conflicts.
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Contraception and Naloxone 
