Subject: CDC Guideline for Prescribing Opioids for Chronic Pain
Dear Dr. Frieden,
On behalf of the American Association of Neurological Surgeons (AANS), Congress of Neurological
Surgeons (CNS), the AANS/CNS Section on Pain and the AANS/CNS Section on Disorders of the Spine
and Peripheral Nerves, we are pleased to offer you the following comments on the CDC’s Guideline for
Prescribing Opioids for Chronic Pain.
Clinical question 1 of the guidelines
The effectiveness of long-term opioid therapy versus placebo, no opioid therapy, or nonopioid
therapy for long term (>1 year) outcomes related to pain, function, and quality of life, and how
effectiveness varies according to the type/cause of pain, patient demographics, and patient
comorbidities (Key Question 1; KQ1).
While page 12 of the guidelines does briefly mention the use of non-opioid medications such as
gabapentin or other antiepileptic and/or antidepressant medications for the treatment of neuropathic
pain, we believe that this discussion could also be applied to Clinical Questions 2 and/or 3 — particularly
with respect to initiating opioid therapy — as the initiation of such therapy may only be indicated for
neuropathic pain refractory to other medications.
Clinical question 4 of the guidelines
The accuracy of instruments for predicting risk for opioid overdose, addiction, abuse, or misuse;
the effectiveness of risk mitigation strategies (use of risk prediction instruments); effectiveness
of risk mitigation strategies including opioid management plans, patient education, urine drug
testing, prescription drug monitoring program (PDMP) data, monitoring instruments, monitoring
intervals, pill counts, and abuse-deterrent formulations for reducing risk for opioid overdose,
addiction, abuse, or misuse; and the comparative effectiveness of treatment strategies for
managing patients with addiction (KQ4).
With respect to measures aimed at predicting risk factors for opioid misuse and effective mitigation
strategies, organized neurosurgery believes that a reference should be made to surgical options for the
treatment of chronic pain — such as intrathecal pain pumps — as this is an effective means of treating
chronic pain in the right patient population. Patients with intrathecal pain pumps are less likely to
experience the systemic side effects of opioids and tend to be weaned entirely off of oral opioids long-
term. As such, we believe that more primary care and pain management providers should be aware of
this potential therapeutic intervention.
Clinical question 5 of the guidelines
The effects of prescribing opioid therapy versus not prescribing opioid therapy for acute pain on
long-term use (KQ5).
We are concerned that recommendations for patients with chronic pain who undergo large surgeries,
such as spinal surgery, are not fully addressed. On page 11 of the guidelines, there is a brief mention of
data demonstrating that patients who undergo minor surgery, such as cataract surgery, are at greater
risk for developing long-term opioid use when more than seven days of postoperative opioids is
prescribed. However, for patients who undergo large spine surgeries — particularly for those in whom
an underlying chronic pain condition is present — a postoperative course of opioids longer than seven
days is often necessary. This distinction of the type of surgery is not clear in the current guidelines.
Moreover, prescribing a short course of postoperative opioids for all surgical patients may result in
severely under-treated postoperative pain.
Thank you for considering our comments. If you have any questions or need further information, please
contact us.
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