Dr. Klubnick
Clinical question: Did the 2016 U.S. Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain change opioid prescribing practices and vaso-occlusive crisis (VOC)-related hospital visits in patients with sickle cell disease (SCD)?
Background: In March 2016, the CDC released the Guideline for Prescribing Opioids for Chronic Pain, which was designed to increase safety and offer guidance regarding the treatment of chronic pain not related to cancer, palliative care, or end-of-life care. This has decreased opioid prescribing among the overall population of the U.S. However, SCD-specific guidelines recommend the use of opioid therapy when non-opioid analgesia has not been effective, and the CDC guideline did not specifically omit patients with SCD.
Study design: Retrospective cohort study
Setting: U.S. patients enrolled in Merative MarketScan Commercial Database (which is made of deidentified patient-level data from insured American patients)
Synopsis: This study used an interrupted time series to examine the change in opioid prescription patterns and VOC-related hospital care in 14,979 patients with SCD before and after March 2016 CDC guidelines for prescribing opioids for chronic pain were implemented. The trend of each measured domain from January 2011 through February 2016 was compared with the trend from March 2016 through December 2019.
The study showed that there was a decrease in the four domains of opioid prescriptions measured after March 2016; dispensing rate per 100 persons (slope -0.001 to -0.004), days supplied per prescription (slope 0.031 to -0.015), total morphine milligram equivalents per person (slope 73.74 to 67.23), mean daily morphine milligram equivalents per person (slope 4.13 to -5.97). Additionally, there was a concomitant increase in VOC-related emergency department visits (slope -0.008 to 0.034) and VOC-related hospitalizations (slope -0.098 to 0.059). These changes were found to be present for both adult and pediatric patients, with the changes present to a greater degree in the adult patient group.
Bottom line: There was a decrease in opioid prescribing for patients with SCD and an increase in VOC-related hospitalizations after the release of the CDC Guidelines for Prescribing Opioids for Chronic Pain in March 2016. This may reflect an unintended negative outcome for patients with SCD. Patients with SCD may benefit from disease-specific exemptions from guidelines related to opioid prescribing in the future.
Citation: Kang HA, Wang B, et al. Opioid prescribing and outcomes in patients with sickle cell disease post–2016 CDC guideline. JAMA Intern Med. 2024;184(5):510-518. doi:10.1001/jamainternmed.2023.8538
Dr Klubnick is an academic hospitalist at UC San Diego Health, at the University of California in San Diego.