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Don't Flinch From Prescribing Pain Medications!

Editor's Memo from April 2016

By now chronic pain patients and practitioners are well aware of the new Center for Disease Control and Prevention (CDC) “Guidelines for Opioids for Chronic Pain” released on March 15, 2016.1 Although these guidelines have been, and will continue to be, strongly criticized for the process by which they were created,2 they are now published. One of the often stated goals of CDC, despite widespread skepticism from many pain specialists, is that they did not want to limit access to pain care. Let’s take them at their word.

CDC Issues New Guidelines on Opioid PrescribingA major “bone of contention” regarding the guidelines is the recommendation that a daily dose of opioid should seldom go over 90 mg equivalents of morphine a day. In the CDC’s words: “Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day.”1

Thankfully, few chronic pain patients require more than 90 MME for pain management. Be alert, however, to the fact that 90 MME in the guidelines is not a maximum ceiling dose but a “trigger” or “call” for a medical-necessity evaluation, including a possible consultation or referral to a pain specialist.

My personal objection about all the new opioid prescribing guidelines, including CDC’s, is that they seem to want all patients on high-dose opioids to be managed by pain specialists rather than primary care physicians (PCPs). Unfortunately we don’t have enough pain specialists to medically manage these legitimate, suffering patients who can’t function or leave the couch without an opioid dosage above 90 MME.

While the intent of the CDC to have the most serious pain patients managed strictly by pain specialists may be laudable, this won’t solve our nation’s epidemic of untreated and undertreated chronic pain. Incidentally, the new guidelines rightfully mention all the risks of high-dose opioids, such as addiction, diversion, and overdose; but they wrongfully fail to mention all the serious, life-shortening, and physiologic impairments that are the risks of undertreated, severe, chronic pain.

Sadly, without opioids, some of these unfortunate individuals will suffer immense physical dysfunction, endocrine failure (see Hormone Testing and Replacement), cardiovascular collapse, immune dysfunction, dementia, and premature death.

This memo is a plea to not discharge severe pain patients who are currently taking over 90 MME or avoid and deny patients who may need this level of opioid in the future. Be aware that the CDC guidelines do not prohibit dosages over 90 MME—what they rightly recommend is that physicians do an assessment and document medical necessity for dosages above that level.

Here are my personal practice policies and recommendations for dealing with past, current, and future patients who require over 90 MME:

  • The pain practitioner has to clearly state, in the patient’s chart, that the patient has severe chronic pain due to a specific underlying cause.3 For a patient to receive high-dosages of opioids, the physician must obtain and document the history, relevant physical exam, laboratory data, informed consent, and past records of treatments that have been tried.
  • Opioids should not be prescribed in isolation. Rather than just continuing to increase the dose, the physician needs to revisit what other modalities are being used or have been tried. These include: non-opioid medications such as an anticonvulsant if the pain has neuropathic elements, (being certain to titrate up to an effective dose); a topical medication such as Lidoderm patch, Voltaren gel, etc.; a physical therapist-guided home exercise program and other physical activities, including massage; consultation with an interventionist if appropriate; assessment and treatment of co-occurring anxiety or depression.

The new guidelines, in my opinion, could worsen a growing problem of access to medication. Already, in some locales, patients can’t obtain prescriptions and insurance companies don’t want to pay for opioids (or much else!!). If patients need a high, costly opioid dosage, they must personally determine the limits of their insurance coverage and identify pharmacies that will supply opioid medications.

We physicians can help but none of us has the time or influence to help every pain patient with his or her personal supply of medication and insurance issues. Simply stated, a patient must be an active rather than traditional, passive patient: pain patients must now join advocacy groups and begin to lobby for their right to obtain opioids and avoid an agonizing existence and premature death.

Millions of chronic pain patients now take opioids responsibly and constructively. While opioids aren’t for everybody, many pain patients who are taking high-dose opioids have enhanced their overall health, achieved a decent quality of life, and have likely extended their life span. These patients don’t abuse, divert, or overdose on their opioids, and they don’t develop hyperalgesia or the need to continually escalate their dosage. Isn’t it time we pay as much attention to these worthy folks as those who non-comply, abuse, and overdose?

To continue this discussion, we asked members of the Practical Pain Management Editorial Board to weigh in with their response to the new guidelines. We highlight the responses 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. To participate in the discussion, please visit leave your comments.

Also in this issue, we have the pleasure of introducing the newest member of the PPM Editorial Board, Don L. Goldenberg, MD. Dr. Goldenberg was Chief of Rheumatology at Newton-Wellesley Hospital and Professor of Medicine at Tufts University School of Medicine from 1989 to 2016. Dr. Goldenberg will be contributing articles in the areas of fibromyalgia, chronic fatigue syndrome, and other chronic pain syndromes.

Last updated on: April 15, 2016
First published on: April 1, 2016
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Don L. Goldenberg, MD, FACP