The Centers for Disease Control and Prevention (CDC) recently sent a letter to representatives of the National Comprehensive Cancer Network (NCCN), the American Society of Clinical Oncology (ASCO), and the American Society of Hematology (ASH) clarifying the position of the CDC, which is that clinical practice guidelines specifically addressing pain management for cancer survivors — as well as those guidelines specifically addressing the use of opioids as part of pain control in patients with sickle cell disease — should be used to guide treatment and reimbursement decisions for these patients.1

This clarification by the CDC was made with respect to guidelines they published in 2016 on prescribing opioids for chronic pain.2 The CDC guidelines were written for primary care clinicians and, while they included cancer survivors, did not cover use of opioids in patients receiving active cancer treatment, palliative care, and end-of-life care. 

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Nevertheless, following a meeting held in November 2018 at which representatives of NCCN, ASCO, ASH, and the CDC met to discuss recently identified areas of discordance between pain management guidelines,3 representatives from NCCN, ASCO, and ASH wrote to the CDC regarding the need for “clarifying the intended audience for CDC guidelines to address unintended implementation and reimbursement consequences that have been occurring in practice”4

Specifically, a major concern was that select groups of cancer survivors, such as those with lingering treatment-related neuropathic pain, or intractable pain due to post-thoracotomy or post-mastectomy syndrome, as well as patients with sickle cell anemia with recurrent or chronic pain due to conditions such as avascular necrosis, leg ulcers, and other neuropathic pain, would not be eligible for opioid-based pain management according to the CDC guidelines. Another concern was that the CDC guideline recommendations could be misinterpreted so as to deny opioids to some patients with cancer undergoing active treatment.

In addressing the concerns expressed by NCCN, ASCO, and ASH, a letter sent to these organizations from Deborah Dowell, MD, MPH, chief medical officer at the CDC’s National Center for Injury Prevention and Control included the following statements:

“As you note, for select groups of cancer survivors with persistent pain due to past cancer or past cancer treatment, the relationship of benefits to risks in use of opioids for chronic pain is unique,” said Deborah Dowell, MD, MPH, Chief Medical Officer at the CDC’s National Center for Injury Prevention and Control.

“As you additionally note, unique considerations in sickle cell disease can change the balance of benefits and risks for the use of opioids in pain management,” Dr Dowell further stated.1 

“CDC’s acknowledgement 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 anemia,” said Robert W. Carlson, MD, NCCN’s chief executive officer.5 

References

  1. Dowell D. Centers for Disease Control and Prevention. [letter to NCCN, ASCO, ASH] Published February 28, 2019. Accessed April 15, 2019. 
  2. Dowell D, Haegerich TM, Chou, R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. Morbidity and Mortality Weekly Report (MMWR). Recommendations and Reports. 2016;65(1):1–49. 
  3. Meghani SH, Vapiwala N. Bridging the critical divide in pain management guidelines from the CDC, NCCN, and ASCO for cancer survivors. JAMA Oncol. 2018;4(10):1323-1324.  
  4. Carlson, RW, Hudis CA, Liggett M. National Comprehensive Cancer Network, American Society of Clinical Oncology, American Society of Hematology [letter to CDC]. Dated February 13, 2019. Accessed April 15, 2019.
  5. American Society of Clinical Oncology. CDC issues key clarification on guideline for prescribing opioids for chronic pain. https://www.asco.org/advocacy-policy/asco-in-action/cdc-issues-key-clarification-guideline-prescribing-opioids-chronic. Accessed April 15, 2019.