Opioid Prescribing and Monitoring - (Second Edition)
Primary Care Models for Pain Management

Foreword

The Centers for Disease Control and Prevention (CDC) published its guidelines for opioid prescribing in the spring of 2016.1 The guidelines, directed mainly toward primary care physicians (PCPs), have set a national standard for opioid selection and dosing and established an expectation for prescribers to evaluate the risks and benefits of opioid therapy for each patient.

Among its recommendations, the CDC noted that “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.”1

Despite the admirable aim of reducing opioid overdoses, however, the guidelines have had a profound and even chilling effect on many clinical practices. In addition, many state medical boards and insurance companies have adopted the CDC guidelines as “the rule of the land,” rather than as recommendations. The resulting confusion has left many chronic pain patients without their opioids and thrown them into de facto “detox.”

The CDC, unfortunately, has said little about the guidelines’ intended and unintended impacts. According to one report, a letter from a top CDC official to a patient characterized the guidelines as only a “guide” for primary care providers “as they work in consultation with their patients.”2 Debra Houry, MD, MPH, director of the CDC’s National Center for Injury Prevention, which oversaw the guidelines’ development, described them similarly in a separate letter. “The Guideline includes a recommendation to taper or reduce dosage only when patient harm outweighs patient benefit of opioid therapy,” she wrote. “The Guideline is not a rule, regulation, or law. It is not intended to deny access to opioid pain medication as an option for pain management. It is not intended to take away physician discretion and decision-making.”3

Informed decision-making, after all, is a cornerstone of our profession and can make a dramatic difference to patients with chronic pain. One recommendation that seems prudent, for example, is to consider a controlled taper for patients who are taking over 90 MME of opioid medication and reporting that their function is not improving or that the risks outweigh the benefits. A dosage reduction of 5% to 10% per month is usually safe and well tolerated.4

Concurrent with opioid reduction, patients should be started on ancillary, nonopioid agents to help control the pain and suppress withdrawal symptoms. However, physicians shouldn’t be surprised if some patients resist this strategy; many have tried adjuvant therapies such as nonsteroidal anti-
inflammatory drugs, gabapentin, and antidepressants prior to starting an opioid prescription. In addition, it’s important to remember that many of the nonpharmaceutical options recommended by the CDC are not always readily available to every patient, such as physical therapy, cognitive behavioral therapy, and exercise programs.5

Amid the ongoing opioid epidemic and lingering uncertainty over the new recommendations, the goal of this year’s special edition is to move the ball forward in discussing how to rationally and safely treat chronic pain. To do so, we have called upon a legal expert to help explain what the guidelines really mean, as well as experts in the field of medical pain management and pharmacology to present an unbiased view of the current state of opioid prescribing and monitoring. We hope that this supplement will help clinicians better understand when to consider prescribing opioids, when to use alternative therapies, how to properly assess and monitor patients prescribed opioids—and perhaps most importantly, how to help patients at risk of or in the midst of opioid misuse or an opioid use disorder.

We hope you find this supplement helpful, and we look forward to your feedback.

Forest Tennant, MD, DrPH
Editor in Chief

Nikki Kean
Former Managing Editor 
 

Last updated on: November 14, 2017
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