Thread by @speakingabtpain

1st impressions of the just-released final 2022 CDC Guideline. The good, the bad, and post-Halloween, the haunting 👻skeleton of 2016 that remains.

A 🧵. cdc.gov/mmwr/volumes/7…
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First, background. The 2016 was widely misapplied in ways that harmed patients (as CDC acknowledged in 2019) 2/

States, health systems, quality metric agencies applied the 2016 guideline strictly as law and mandate 3/

And, pain patients on opioids were abandoned & cut off their medication. Acc to studies, 50% of primary care doctors will refuse to treat such patients, opioid taper or cessation actually INCREASES risks of OVERDOSE and SUICIDE by 3 - 5 X. 4/

The assumptions of policymakers were twofold: 1) we cut the medical supply and we lower overdoses (which have escalated exponentially) and 2) if we take people off their medication, we make them safer. Both manifestly wrong. 5/

THE GOOD: CDC authors state in a Perspective article in NEJM that they will monitor to protect against misapplication of the 2022 Guideline. I’d love for an enterprising journalist to find out what that means…. But it’s important, given the history 6/

But it’s good news, since I have seen no slow down, including since they issued a corrective in 2019, in the number of desperate patients I hear from. Literally 10s of 1000s 7/

And the Guideline backs this up. Strewn throughout and not just in the introduction are admonitions against misapplications like this one 8/

Fair warning that all of those policymakers who misapplied the 2016 Guidelines — especially its dose and day thresholds — need to course correct NOW. 9/

The Guideline repeatedly emphasizes that pain is heterogeneous, that care must be individualized, patient-centered. It emphasizes that the guideline is voluntary and is not a substitute for clinician judgment.

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The section on tapering has significant improvements: it comes out against forced & abrupt tapers, adds many of the studies showing risk of taper, including Fenton and Larochelle, showing risks occur regardless of pace and can last 2 years.
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It harmonizes with prior HHS Guidance. In some places it still cites studies involving tiny samples. But it underscores risks, including nothing that a benefit to continuing medication in making risk benefit calculus might be avoiding the risks of tapering.

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Elsewhere, the soften their stance on #DrugTesting. Recommendation 10 used to say clinicians should consider using toxicology screening. Now says "clinicians should consider the benefits and risks of toxicology screening."

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They softened in the tiniest way Recommendation 11 about prescribing opioids with benzodiazepines or other CNS depressants changing the admonition that clinicians should use "extreme" caution to "particular" caution.

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They still recommend checking PDMPS, but contain more in the body of the text cautioning against misuse of PDMP data.

Back in a second with the bad/haunting
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