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15 Articles in Volume 18, Issue #5
Chronic Pelvic Pain: The Need for Earlier Diagnosis and Diverse Treatment
Cross-Linked Hyaluronic Acid for the Management of Neuropathic Pelvic Pain
Fentanyl: Separating Fact from Fiction
Gender Bias and the Ongoing Need to Acknowledge Women’s Pain
Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain
Post-Menopausal MSK Pain and Quality of Life
PPM Welcomes Dr. Fudin and Dr. Gudin as New Co-Editors
Practitioner as Patient: Understanding Disparities in CRPS
States Take Action to Manage Opioid Addiction
Step-by-Step Injection Technique to Target Endometriosis-Related Neuropathic Pelvic Pain
The Many Gender Gaps in Pain Medicine
The Need for Better Responses to Vulvar Pain
Topical Analgesics for Chronic Pain Conditions
Topical Medications for Common Orofacial Pain Conditions
What’s the safest, effective way to taper a patient off of opioid therapy?

Letters to the Editor: 90 MME/day Ceiling; Ehlers-Danlos; Redefining Pain

July/August 2018 PPM Letters to the Editor from practitioner peers and patients

The 90 MME/day Ceiling

Dear PPM,

I am a board-certified anesthesiologist practicing pain management. In your June 2018 issue, Dr. Tennant stated: “multiple federal agencies have made it clear that any physician who prescribes over 90 MME/day will be taking on serious legal liability.” I have assumed the care of a few patients that came in from another office that closed and they are over 90 MME/day. I will make every effort to decrease their dosage, but this is difficult as they have had severe injuries and have been on higher dosage for many years. Each of them has stated that they couldn’t possibly function or carry on with their daily household duties without their current opioids. I could discharge these patients, send them to the county methadone clinic, or continue my attempts to lower their dosage but I don’t sleep well at night. Thank you for your assistance.

–K.B., MD 

Dear Dr. K.B.,

You describe in your letter what is often called a “legacy” pain patient. These are seriously ill or injured persons who were put on high dose opioids several years ago simply because we physicians didn’t have much else to offer except humanitarian, symptomatic pan relief. Patients today, in my experience, seldom need over 90 MME/day as we have many non-opioid measures and alternatives. My recommendation with legacy patients is to first determine if the patient is receiving palliative care as this type of care is cited by the Centers for Disease Control and Prevention (CDC) as a reason to exceed 90 MME/day. I use the following definition of palliative care: daily medical treatment of a severe intractable pain patient who has a shortened life expectancy due to the patient’s underlying, painful disease and who requires caregiver support to carry out some activities of daily living. Palliative care may include treatment that might cure a serious illness or slow its progress. Patients for whom palliative care is indicated are likely to die within one year if untreated.

I recommend you have a family member declare the need for palliative care, and I also recommend that you file a certificate of need for palliative care in the patient’s chart and with the patient’s pharmacy. Placing patients on non-opioid alternatives and a taper plan is a good idea, but many high and ultra-high dose legacy patients simply will not be able to survive if they reduce their dosage down to 90 MME/day.

I do not recommend keeping many high-dose opioid patients in your practice. It may not be right or fair, but too many anti-opioid parties feel that a physician, even a board-certified specialist, who has a lot of high-dose opioid patients could be a “pill pusher.”

I would like to add that, overall, you are not alone in your situation. Many other physicians have had sleepless nights as a result of the 90 MME/day guideline. The controversy all started when the CDC issued guidelines in 2016 for primary care physicians, which recommended they not prescribe over 90 MME/day unless the patient is in palliative or end-of-life care.

These well-meaning guidelines have had numerous unintended consequences, including thrusting extreme liability onto any physician who dares prescribe above 90 MME/day. Consequently, many, if not most physicians throughout the country will no longer prescribe above this level, and many physicians have stopped prescribing even small amounts of opioids.

The crux of the problem is that multiple powerful institutions and entities, governmental and nongovernmental, are now claiming that 90 MME/day is a maximal, ceiling dosage and not a “guideline.” Furthermore, this “ceiling” applies to all physicians, not just primary care doctors. Physicians who practice pain management are now being bombarded with a 90 MME/day ceiling with direct and indirect “threats” about going above this level.

Regulatory agencies and boards are now reportedly monitoring prescriptions to identify physicians who prescribe above this level and may launch an investigation of the prescribing physicians for inappropriate, “reckless,” or diversionary prescribing based on this computer-generated prescribing data.

The Centers for Medicare and Medicaid have recently sent letters to many physicians about exceeding their prescribing quota of opioids, and that they may be audited or required to personally reimburse the federal government for the cost of opioids. Further, some insurance companies and drugstore chains are publicly stating that any dose above 90 MME/day is not indicated and may be dangerous (eg, high risk of overdose). Some insurance companies are using the “ceiling” to deny coverage and some pharmacies refuse to fill prescriptions over 90 MME/day.

One of the greatest legal liabilities for physicians that have come out of the 90 MME/day “ceiling” is the carryover into malpractice risk. Some malpractice carriers, local hospitals, and medical groups are now admonishing physicians not to prescribe above 90 MME/day due to malpractice risk. The theory is that any patient taking over 90 MME/day who has an accident, fall, or overdose, may be the result of physician negligence.

Let’s hope the hysteria and misinformation about opioids soon passes. The drive to establish 90 MME/day as an “absolute ceiling” regardless of pain severity, underlying disease, or genetic metabolic abnormalities is causing far too many worthy pain patients to endure tragic suffering and, in some cases, to commit suicide. The good news is that pain patients and families are now organizing and beginning political pushback.

–Forest Tennant, MD, Editor Emeritus

Dear Dr. K.B.,

The federal government has repeatedly stated its views that, as a general guideline, practitioners should not prescribe more than 90 MME/day. These guidelines can be found, for example, on the CDC website. It is important to note that these are just guidelines and not bright-line rules.

As a general matter, when opioids are started, clinicians should prescribe the lowest effective dosage. It is a best practice to use caution when prescribing opioids at any dosage and practitioners would be well-advised to carefully reassess evidence of individual benefits and risks when prescribing opioids, particularly where dosage is 50 MME/day.

Other best practices include considering offering naloxone when a patient is at risk for opioid overdose, reviewing patients’ prescription drug monitoring program data, and using urine drug toxicology tests to confirm patients’ compliance. As with most things, these suggestions are just that – suggestions that ultimately will need to be modified to a physician’s individual needs.

–Jason Mehta, Partner, Bradley Arant Boult Cummings

Ehlers-Danlos on the Rise; More Research Needed

In the June 2018 issue, Dr. E. Gordon asked about treating patients that meet criteria for chronic fatigue syndrome, hypermobility, and Ehlers-Danlos Syndrome (EDS). Below is a response:

Dear Dr. Gordon,

You touch upon an emerging public health issue. I have personally found, as have you, that the percentage of severe chronic pain patients with EDS seems to be increasing. Perhaps we are just more aware, but hypermobile EDS seems to almost to be proliferating!

You are correct when you say there has been no support for these misunderstood individuals. I pass along two observations I have made involving this group of patients. Rarely do they genetically test positive for any of the sub-types (eg, vascular) of EDS. Since there is no genetic test for the hypermobile type, patients may not be too accepting of their situation. Nevertheless, EDS is a clinical diagnosis that must be made as its tissue degeneration and complications may lead to profound pathologic changes, impairments, suffering, and early death. My second observation is that EDS patients who manage to find comfort and good function are simultaneously treated with a potent anti-inflammatory regimen (eg, ketorolac, low dose methylprednisolone) and hormone stimulation (eg, nandrolone, human chorionic gonadotropin). The repair of connective tissue that has degenerated appears, to me, to be dependent upon a medical regimen that concomitantly reduces inflammation and repairs tissue.

Without question, we urgently need research on EDS and pain care. Unfortunately, the type of research we all like best takes time, money, and diligence. In the meantime, EDS patients and physicians should share their experiences to help this misunderstood group.

–Forest Tennant, MD, Editor Emeritus

Redefining “Pain”

PAIN Reports, a journal of the International Association for the Study of Pain (IASP), recently published a paper suggesting a revised definition of pain. Led by Cohen et al., the authors reviewed the history of the IASP definition for pain and its 40 years of revisions. The definition put forth in 1979 was: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

The authors found that a greater scope should be applied to the definition to include its phenomenology, social intersubjective space, and existing language limitations around the world. They ultimately proposed: “Pain is a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.” (The authors’ proposal does not represent a formal IASP opinion or revision.)

Here, Michele Yurgil, MSN, RN, ACNS-BC, APN, shares her thoughts. “I thought I’d offer some commentary on the idea of changing the 1979 definition of pain. I still think it is appropriate. Most patients find pain unpleasant, and the physical/somatic experience as well as the psychological component of pain play heavily into the patient’s pain experience. Plus, at this point in time, it’s their experience along with their individualized report of pain we try to manage. Thus, I prefer the current definition. It still fits well with the patients I see and the nurses I teach.”

Last updated on: August 3, 2018
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