Am Fam Physician. 2016;93(12):975
Related Practice Guideline: CDC Develops Guideline for Opioid Prescribing
Author disclosure: No relevant financial affiliations.
The opioid epidemic that is afflicting our nation resulted in nearly 30,000 deaths last year. Those of us responsible for health care and policy are looking at ways to stop these needless deaths. It is our professional and ethical responsibility as physicians to help bring this epidemic to an end.
In 2014, the American Medical Association (AMA) assembled more than 25 physician groups and the American Dental Association as part of our Task Force to Reduce Prescription Opioid Abuse. It developed practical recommendations ( http://www.ama-assn.org/ama/pub/advocacy/topics/preventing-opioid-abuse/opioid-abuse-task-force.page?) for physicians and policy makers that we believe will help end the nation's prescription opioid and heroin epidemic.1 The AMA has worked with the National Governors Association and other leading stakeholders on implementing proven state legislative solutions. In partnership with the Obama administration and other groups, we are reaching out to physicians about appropriate prescribing practices and ways to be part of the solution. That includes having more than 500,000 health care professionals complete opioid prescribing training in the next two years; doubling the number of physicians certified to prescribe buprenorphine for treatment of opioid use disorder; doubling the number of clinicians who prescribe naloxone; and doubling the number of health care professionals registered with their state prescription drug monitoring programs in the next two years. We also have urged Congress to join us in developing and supporting approaches to this public health epidemic.
Earlier this year, AMA President Steven J. Stack, MD, issued a national call to action for physicians to amplify our leadership on this issue and take responsibility for finding solutions and for implementing the recommendations of the task force. State legislatures, patient organizations, and other public and private entities have also become engaged. However, more resources, compassion, and understanding are required.
The Centers for Disease Control and Prevention (CDC) recently issued a guideline on opioid prescribing.2 The AMA shares the CDC's goal of reducing harm from opioid misuse and applauds the agency for making this a high priority. The AMA largely supports the CDC guidance. However, we have concerns about areas where the recommendations lack patient or practice specificity, and about the fact that the guideline does not address current payment models and insurance coverage for treating chronic pain, which are widely recognized as insufficient.
Specifically, we are concerned about the recommendations for specific dosage and duration limits, which are based on low- to very low-quality evidence and opinion. We understand the CDC's intent, and we agree with the goal that when opioids are appropriate, the physician should prescribe the lowest effective dose for the shortest effective duration. Prescribing judiciously is not unique to clinical decisions for pain management, but is a general tenet of designing a dosage regimen and treatment plan.
The CDC recommendations also have the potential to cause confusion in light of institutional or state policies. For example, the recommendations on dosage and duration limits conflict with the approved product labeling for opioids and with the U.S. Food and Drug Administration's own conclusions about the wisdom of establishing a maximum dose based on daily morphine milligram equivalents. We are concerned that insurers and other payers will use the recommendations to deny or impose new hurdles to coverage of any dose that exceeds the CDC's recommended thresholds. We are concerned that pharmacies will be under pressure to deny prescriptions that exceed those thresholds, and that patients who require more than 50 morphine milligram equivalents per day could face additional prejudice and stigma.
If the CDC proposals reduce deaths resulting from misuse of opioids, they will prove to be valuable. If they result in unintended consequences, we will need to mitigate them. Overall, the AMA shares the CDC's goal of saving lives and reversing this epidemic, and we will be working with the agency and others to take steps in this direction.