CDC's clarification letter notes that the agency's guideline was developed to provide recommendations for primary care clinicians who prescribe opioids for patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The letter conveys that CDC's guideline is not intended to deny clinically-appropriate opioid therapy to any patients who suffer acute or chronic pain from conditions such as cancer and sickle cell disease, but rather to ensure that physicians and patients consider all safe and effective treatment options for pain management with the goal of reducing inappropriate use.
"This clarification from CDC is critically important because, while the agency's guideline clearly states that it is not intended to apply to patients during active cancer and sickle cell disease treatment, many payers have been inappropriately using it to make opioid coverage determinations for those exact populations," said ASCO Chief Executive Officer Clifford A. Hudis, MD, FACP, FASCO.The CDC's clarification further notes that clinical practice guidelines addressing pain control for survivors of cancer, such as the American Society of Clinical Oncology Clinical Practice Guideline on Management of Chronic Pain in Survivors of Adult Cancers and the National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Adult Cancer Pain, which were published and/or updated more recently than CDC's guideline, provide important guidance on the unique considerations when using opioids to control pain in cancer survivors without worsening the current opioid crisis.
"Pragmatic approaches for pain management exist at the intersection of multiple health concerns," said NCCN Chief Executive Officer Robert W. Carlson, MD. "Our guidelines help clinicians to assess the risk of inappropriate substance use, while still ensuring people with cancer don't suffer unnecessary, severe pain. CDC's acknowledgment that clinical decision-making should be based on the relationship between physicians and their patients is important and in the best interest of people with cancer and sickle cell disease."
In November 2018, ASCO, ASH, CDC, and NCCN representatives met in-person to discuss concordance and variation among current guidelines for chronic pain management and develop a strategy to resolve inconsistencies as well as improve communication of existing recommendations. External reviews had previously identified perceived inconsistencies among existing guidelines and had noted concern that such inconsistencies may be causing inadvertent confusion in the healthcare community. The organizations also discussed issues related to the CDC guidelines and agreed jointly to seek clarification of the guidelines regarding their applicability to patients with cancer and sickle cell disease. Following the meeting, ASCO, ASH, and NCCN sent a letter to CDC urging the clarification.
"People with sickle cell disease suffer from severe, chronic pain, which is debilitating on its own without the added burden of having to constantly appeal to the insurance companies every time a pain crisis hits and the initial request is denied," said ASH President Roy Silverstein, MD. "We appreciate CDC's acknowledgment that the challenges of managing severe and chronic pain in conditions such as sickle cell disease require special consideration, and we hope payers will take the CDC's clarification into account to ensure that patients' pain management needs are covered."
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