May 09, 2019 04:01 pm Chris Crawford – According to an April 24 CDC media statement, a recent commentary in the New England Journal of Medicine penned by authors of the agency's Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016, warned that misapplication of the guideline can risk patient health and safety.
The commentary's authors outlined examples of how the guideline, which is intended to be used by primary care physicians who are treating chronic pain in patients age 18 and older, has been misapplied. They also highlight advice it contains that is critical for safe and effective implementation of the recommendations.
As a reminder, the AAFP's Commission on the Health of the Public and Science gave the guideline its "affirmation of value" designation in April 2016, agreeing with some of its recommendations but expressing concerns about others based on the methodology used and a lack of supporting evidence.
Robert "Chuck" Rich, M.D., of Bladenboro, N.C., who represents the AAFP on the AMA Task Force to Reduce Opioid Abuse and participated on the CDC Core Expert Group that helped create the guideline, told AAFP News that because the guideline's recommendations have been incorrectly interpreted as care standards by insurers, regulatory agencies, health systems and other organizations, and have been applied to all categories of patients with pain, the result has been inappropriate pain care management for some patients, particularly those who are already using opioids as part of their care regimen.
"As a guideline with a limited evidence base, both pro and con, for the use of opioids in chronic pain, it was never meant to be interpreted as rules and standards of care for the pain patient," Rich said. "The intent was to help the primary care professional through a shared decision-making process with their patient, determining the best options for the treatment of chronic pain, including the use of opioids as appropriate."
Misuse of the guideline, according to CDC officials, has included applying its recommendations to patients in active cancer treatment, those experiencing acute sickle cell crises or patients suffering post-surgical pain.
Various other organizations are currently working to develop guidance for treatment of pain in these subgroups of patients, Rich said.
"The pain treatment requirements for the management of pain in these groups could easily surpass the 90 MME (morphine milligram equivalents) recommendation -- the suggested top end of dosing in patients for chronic pain from the CDC guideline," he said. "The circumstances surrounding pain in each of these groups is different from (those of) the typical patient with chronic pain, and each group must be considered individually for the relief of pain and suffering."
Other examples of misapplication have included instituting hard limits on, or even cutting off, opioid use in patients already prescribed higher dosages -- 90 MME or more per day. The agency said that its recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.
The CDC identified the 90 MME per day threshold as a soft cutoff based on data showing that the risk of accidental overdose and other complications increases exponentially after that level, Rich said.
"In patients not previously exposed to opioids, this remains a goal that I fully endorse -- keeping the patient to the lowest effective dose based upon an ongoing assessment of pain and function," he said. "For those patients already taking opioids for chronic pain, many are already at or above that level, and efforts to limit those patients to 90 MME per day could easily precipitate worsened pain and lessened functional capacity."
Furthermore, said Rich, rapid tapers or abrupt discontinuation of opioids in patients already dependent on the medication for pain control will precipitate opioid withdrawal, which is clearly painful and dangerous for patients.
"In an effort to lessen the effects of withdrawal, the patient may turn to street drugs or other inappropriate medications with other unintended consequences," he noted.
One other significant misapplication of the guideline is that its dosage recommendation does not apply to patients receiving or starting medication-assisted treatment for opioid use disorder. It applies only to use of opioids to manage chronic pain.
"The CDC guideline primarily focused on the treatment of chronic pain, and the subject of MAT for the treatment of opioid use disorder is a separate issue, which is better addressed by other guidelines," Rich said.
The agency said in its statement that the guideline was intended to ensure that primary care clinicians work with patients to consider all safe and effective treatment options for pain management.
"The CDC encourages clinicians to continue to use their clinical judgment, base treatment on what they know about their patients, maximize use of safe and effective non-opioid treatments and consider the use of opioids only if their benefits are likely to outweigh their risks," said the statement.
Robert "Chuck" Rich, M.D., of Bladenboro, N.C., who participated on the CDC Core Expert Group that helped create the agency's Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016, told AAFP News he follows these principles -- which parallel the CDC guideline -- when treating patients with chronic pain:
1. Fully understand the source of the patient's pain and what factors have been used previously to guide the selection of future therapies.
2. Assess the impact of the pain on the patient's level of functioning and reassess periodically and in response to changes in therapy.
3. Maximize the use of adjunctive therapies to lessen the need to use opioids or reduce the dose, if possible, in patients already taking opioids.
4. Use the lowest effective dose when starting opioids and escalate the dose slowly if dosage increases are necessary.
5. Continually reassess goals and objectives for the use of opioids in the treatment of pain with your patient.
6. Constantly monitor your patient's response to and compliance with their opioid therapeutic regimen using tools such as functional assessment screens, periodic drug screens, data available in your state's prescription drug monitoring program and pill counts. The AAFP offers a chronic pain toolkit that features many of these items.
The CDC acknowledged in its statement that patients may encounter challenges with availability of and coverage for non-opioid treatments, including nonpharmacologic therapies (e.g., physical therapy).
"Efforts to improve use of opioids will be more effective and successful over time as effective non-opioid treatments are more widely used and supported by payers," the agency said.
The use of adjunctive medications such as antidepressants and anticonvulsants, as well as nonmedication treatments such as chiropractic and acupuncture, has the potential in many cases to lessen the need for, or even surpass the efficacy of, opioids for many pain syndromes, said Rich.
"While it's true that the evidence base for many adjunctive treatments is limited, this is an area where there is active research that may better guide our treatments in the future," he said. "I acknowledge that many of us have experienced problems with the coverage of adjunctive treatments and medications by insurers.
"But the Academy, along with other professional organizations, has actively advocated for expanded coverage of adjunctive therapies, and insurers are indeed starting to better cover those therapies."
Finally, Rich said each patient currently being treated with opioids represents potential challenges and opportunities for family medicine practices and deserves patience and a full understanding of their pain processes and what led to the decision to use opioids.
"That may require a significant time commitment on our part to properly care for these patients beyond just passing out a prescription for opioids or saying, 'I don't treat pain patients,'" he said. "In my current practice environment, I can't think of a more challenging patient population or one more deserving of our compassion and commitment to properly relieve pain and suffering."
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