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Updated Opioid Guidelines Released for State Medical Boards

June 23, 2017
Guidelines emphasize individual treatment as opposed to rigid standards.

The Federation of State Medical Boards (FSMB) released updated guidelines for using opioid analgesics to manage chronic, non-cancer pain.1 The updated document, which stresses safety through an individualized treatment approach, aligns with recent opioid advisories from the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA).

The guidelines apply to the treatment of chronic pain lasting more than 3 months, and provide state medical and osteopathic boards a general roadmap for safe, evidence-based opioid therapy.

Bob Twillman, PhD, Executive Director of the Academy of Integrative Pain Management.“The guidelines clearly lay out what you should consider in advance of prescribing, how you should evaluate, what you should be monitoring, and what outcomes you should look for,” said Bob Twillman, PhD, FAPM, executive director of the Academy of Integrative Pain Management. “Plus, it shares what to do if the treatments aren’t working, which is novel in these kinds of guidelines.”

Highlights From the Guidelines

The following are key points practicing pain specialists should know from the updated opioid guidelines:

  • Patient evaluation and risk assessment: Clinicians should understand both the patient’s personal and family history of mental health disorders before prescribing opioids. Patients should also receive a mental health screening as part of the initial evaluation.
  • Starting and discontinuing opioids: Nonopioid and nonpharmacologic first-line treatments, with opioids used only after those conservative treatments have failed. When starting a course of opioid therapy, clinicians should have a strategy for discontinuing or tapering of opioid therapy.
  • Keeping the patient informed: Patients should have full understanding of the risks, benefits, and proper use of opioid therapy. Written informed consent and treatment agreements help to crystallize the shared understanding between clinician and patient.
  • Special warning about opioid use with benzodiazepines: Opioid’s adverse effects increase when used concurrently with benzodiazepines, and clinicians should avoid prescribing them at the same time.
  • State prescription drug monitoring programs (PDMP): Clinicians should check state PDMPs before prescribing opioids. PDMPs should also be used to monitor patients throughout treatment to ensure they’re receiving appropriate prescriptions.
  • Note on naloxone: Clinicians should consider prescribing naloxone for all patients with an opioid prescription to use in case of overdose.

Guidelines Versus Standards: Pros and Cons

The guidelines are a resource that provides “overall guidance” to state medical and osteopathic boards in reviewing whether opioids are being used appropriately. As such, they are not a specific standard of care.

The broad nature of the guidelines has its merits and drawbacks, Dr. Twillman said. “For example, it talks in generalities about people being on high or low doses without giving a range,” he said. “That leaves room for medical boards to set their own minimums or limits in doses, and that can be problematic.”

On the other hand, Dr. Twillman noted the flexibility built into the guidelines encourages clinicians to take a more individualized approach to care rather than relying on set-in-stone standards that can inadvertently depersonalize the patient experience. “The take-home message is that clinicians really have to do a comprehensive assessment of the patient,” Dr. Twillman said. “It’s not just about what is going on with them biologically. You have to cover the multitude of factors that go into the experience of chronic pain—including depression and anxiety—to determine the most appropriate treatment.”

From Theory to Practice: Barriers to Following the Guidelines

The guidelines provide a framework to help state boards and clinicians safely and effectively use opioids to manage chronic pain. But, one big barrier exists: awareness.

Jeffrey Gudin, MD, Director of Pain Management and Palliative Care at Englewood Hospital and Medical Center.“Ninety-nine percent of clinician prescribers have never heard of the FSMB or these guidelines,” said Jeffrey Gudin, MD, director of Pain Management and Palliative Care at Englewood Hospital and Medical Center in Englewood, NJ, and member Practical Pain Management Editorial Board member.

While Dr. Gudin believes that the guidelines are well worded and easy to read, he said better promotion would lead to more widespread use and practice. [See PPM's Safe Opioid Prescribing and Monitoring.]  “These guidelines should be picked up by primary care societies and journals, as well as state medical boards and promoted. Perhaps the guidelines could be incorporated into free continuing medical education (CME),” he concluded.

Last updated on: June 23, 2017
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Risk Assessment: Safe Opioid Prescribing Tools

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