CDC Issues Final Guidelines for Opioid Prescribing: PPM Editorial Board Responds
In 2013, nearly 2 million Americans aged 12 years or older either abused or were dependent on opioid drugs, according to the Centers for Disease Control and Prevention (CDC). In that same year, more than 16,000 Americans died from overdoses related to prescription opioid drugs—the height of opioid prescribing.
In response to this epidemic of death from overdoses of opioids, the CDC has issued recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain who do not have cancer or who are not in palliative care. The official—and voluntary—recommendations, known as the “Guidelines for Opioids for Chronic Pain” were released on March 15, 2016.1
The initial draft guidelines were met with sharp criticism from a number of medical organizations, including the American Academy of Pain Medicine (AAPM), American Medical Association (AMA), and the American Academy of Pain Management.2 In addition, the Food and Drug Administration has released its own action plan to address the opioid epidemic.3
To measure the pulse of pain physicians, Practical Pain Management solicited responses from our editorial board members. What follows are the reactions from Jennifer Schneider, MD, a pain and addiction specialist; Gary W. Jay, MD, FAAPM, FACFEI, a pain practitioner; Leonard Goldstein, DDS, PhD, a licensed dentist and acupuncturist; and Elmer Pinzon, MD, MPH, an interventional pain specialist.
Their views offer insight to and interpretation of the 12 recommendations contained in the document,which the CDC hopes to modify as more research becomes available (Table 1). To view the official guidelines, visit www.CDC.gov.
CDC Recommendations Fall Short—Ignore Important Aspects of Pain Management
By Jennifer P. Schneider, MD, PhD
For several years I have been teaching a remedial (or proactive) course, “Opioids, Pain Management, and Addiction” in several locations across the U.S.4 The course was developed for all prescribers as well as other physicians, physician assistants, and nurse practitioners who are dealing with administrative or disciplinary licensing board issues related to their prescribing of controlled substances.
As a result, I am familiar with what can go wrong when treating chronic pain, as well as how to do it right. I have learned that too many well-intentioned prescribers are solely focused on relieving chronic pain without understanding the need for risk assessment and without recognizing that a major goal of treating chronic pain is to improve the patient’s functioning. This involves incorporating modalities such as physical therapy (PT), exercise, and attention to behavioral health issues, which all too often have a significant impact on the patient’s pain.
At the other extreme are clinicians who believe there is no, or a minimal, role for opioids in the treatment of chronic pain. Neither of these approaches is in the patient’s best interest.
Why The Recommendations Fall Short
When I heard that new guidelines were in the works, I was hopeful that they would indeed include discussion of these critical elements. Unfortunately, I was disappointed.
There is nothing new about the recently published CDC guidelines. The 12 recommendations are a mixture of guidelines that have been in existence for many years, along with some useless or irrelevant recommendations as well as statements that are not evidence based and that will be a disservice for many patients if they are followed.
Here is my review of each recommendation:
#1. Agree. “Non-drug therapy and nonopioid therapy should be considered first”; pain and function should both be evaluated, and that opioids, when used, should be combined with non-opioid medications and other modalities.
#2. Disagree. PT is important but is not stressed in the guidelines. I agree that “Goals need to be established on the first visit and subsequent visits should assess improvements in both pain and function.” But I don’t agree that assessment of improvement in pain and function “that outweighs the risks to patient safety” is the main reason to continue opioids. The main reason is the improvement in the patient’s pain and function. Obviously, avoiding side effects is part of that picture, but not the main goal.
In my opinion, function should be stressed more. Patients should be asked—at every visit—to describe specific activities that they can do at home, and to explain the length and intensity of those activities. Unfortunately what often happens is that the prescriber does little more than rate the patient’s “function” on a scale of 1-10 or checks a box on the template indicating “improved function.”
PT should be a key recommendation, and should include a plan for home exercises and activities based on the individual patient’s symptoms and needs. When a patient reports that “PT didn’t work,” rather than recording in the chart that PT failed, a conversation should be started so the patient understands the goals of PT and the important role of activity in minimizing the progression of muscle weakness and disability.
#3. Reality check. With regards to “periodic discussions with patients [about] known risks and realistic benefits of opioid therapy”…. I have reviewed templates of electronic medical records and found that when there’s a box to check on each visit confirming that the matter was discussed the reality is that the box usually gets checked, but the provider doesn’t actually take the time to discuss the matter. This is unfortunate.
#4. Unacceptable omission. “When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release.” I agree. When opioid-naïve patients start an opioid, the dose is typically low, in order to assess side-effects such as sedation and nausea/vomiting, and later titrated upwards to efficacy. If a side effect occurs, it certainly makes sense to have a short-acting formulation rather than allowing patients to be miserable all day. But there is no mention in this guideline of what to do when the opioid is continued!!!! This is an unacceptable oversight.