Clinician Insights

Most Physicians Lean Toward Adopting CDC Opioid Guidelines

April 13, 2016

Roughly 3 in 4 physicians said in a Medscape Medical News poll that they lean toward adopting the stricter guidelines on prescribing opioids for chronic pain that the Centers for Disease Control and Prevention (CDC) issued in March to combat an epidemic of addiction and overdose deaths.

The guidelines, aimed at primary care prescribers, state that opioids should not be considered as first-line therapy for chronic pain and that clinicians should first consider nonopioid pain relievers or nondrug alternatives, such as exercise, meditation, and cognitive-behavioral therapy.

Although 76% of physicians said in the online poll that they were very (49%) or somewhat (27%) likely to incorporate the CDC's recommendations into their practice, they also pointed to roadblocks in their way. These include pressure from patients to prescribe opioids and the lack of third-party reimbursement for nondrug treatment of chronic pain. 'Nurses, including advanced practice nurses (APNs), were slightly less willing (62%) to embrace the government's recommendations.

Table 1. Clinician Likeliness to Incorporate CDC Opioid Guidelines Into Their Practice

Responses All Physicians (%) Nurses, Including Advanced Practice Nurses (%) All Respondents (%)
Very likely 49 36 41
Somewhat likely 27 26 26
Not very likely 10 14 13
Not at all likely 8 12 13
Uncertain 3 9 7

 

For many clinicians, treating chronic pain is a significant part of their work. Thirty-five percent of all physicians said they see 31 or more patients with chronic pain per month, or slightly more than one a day on average.

Of the 483 Medscape readers who completed the poll as of noon on April 6, 241 were physicians, and of that number, roughly 20% were from outside the United States. Ninety-four nurses, including APNs, also weighed in.

"Good to Know I Was Right All Along"

In comments posted on the poll, some readers affirmed the CDC guidelines for prescribing opioids. One family physician wrote that it was the government's responsibility to respond to the "huge problem" of opioid abuse that is killing 40 people a day. "I am going to strive to work with the guidelines and refer when the tools of my disposal have been exhausted," he wrote.

A number of physicians indicated that the new government guidance is old hat to them. "CDC's guidelines align with decades of evidence based medicine," wrote one pain management physician. An internist exclaimed, "Good to know that I was right all along — denying patients opiates when other docs handed them out like candy — ridiculous!"

Contrary to what the poll results might suggest, however, most readers commenting on the guidelines expressed dismay. Many of them warned that the CDC recommendations, if followed, would make it so hard for patients in pain to get relief that they would turn to illegal street drugs, such as heroin. "I wonder how long it will be [before] any 'unintended consequences'…begin to appear?" asked one neurologist. "Will the number of 'accidental deaths' actually increase?"

Other readers predicted that stricter prescribing of opioids will drive some desperate pain patients to commit suicide. "Get ready for a big increase," said one pain management physician.

Another thread in antiguideline comments was resentment of a perceived government intrusion into the practice of medicine. A psychiatrist put it like this: "Kindly allow us to make the independent decisions about prescribing, for which we obtained a medical doctorate."

Acceptance of the guidelines may be grudging. "I worry that most docs will want to follow them to feel protected against potential lawsuits," wrote a healthcare administrator.

What About the Patients Already Taking Opioids?

Some of the criticism that Medscape readers leveled against the CDC opioid guidelines center on their real-world feasibility. The Medscape poll attempted to better understand that complaint by asking readers to identify the biggest barrier to implementation from a list of four that readers frequently mentioned in article comments.

Table 2. What Do Clinicians See as the Biggest Obstacle to Following These Guidelines?

Responses All Physicians (%) Nurses, Including Advanced Practice Nurses (%) All Respondents (%)
Not enough safe pharmalogic alternatives to treat pain effectively 21 23 28
Lack of insurance coverage for nonpharmalogic modalities 19 20 17
Concerns about patient complaints, low satisfaction scores when pain isn't resolved with nonopioids 20 14 19
Patients already receiving opioids for chronic pain 33 31 30
Other 6 9 6

 

The obstacle identified by the most physicians (33%) as number one is that many patients already take opioids for chronic pain. Physicians question whether they can switch these patients to nonopioid analgesics or nondrug therapy. "The CDC doesn't seem to have any recommendations about what to do for them," said one family physician. A clinical nurse specialist asked, "If a patient has been stable for years on a regimen [of opioids] and is not demanding more, where is the problem?"

To 21% of physicians, the biggest hindrance to implementation is not enough safe pharmaceutical alternatives to opioids for effective pain relief. In the words of one family physician, "acetaminophen doesn't work [and] NSAIDs [nonsteroidal anti-inflammatory drugs] cause renal failure and GI [gastrointestinal] bleeding. Insurance won't pay for topicals; steroid injections, at least into the spine, are rarely ever effective."

A nearly identical proportion of physicians put lack of insurance coverage for nonpharmaceutical treatment of pain at the top of the obstacle list. "It would be nice if Medicare put their money where their mouth is in regard to paying for functional recovery programs to get long-term users off the opioids," wrote one physician. "They agree it works, but won't pay for it, at least in Michigan."

Another one in five physicians pointed to the problem of patient complaints and low patient satisfaction scores when nonopioid pain relief doesn't work. In their article comments, many physicians trace this phenomenon back to the movement in healthcare to make pain the fifth vital sign and never undertreat it. "As long as hospitals pay attention to patient satisfaction surveys, [patients] will be getting their happy pills," said an emergency medicine physician.

A colleague added, "Let ER [emergency room] and primary doctors feel empowered to say no to drug-seeking patients without fear of reprisal from administrators who are ignorant of what drives true quality."

Along those lines, many physicians contended that the opioid epidemic is not "doctor driven," as CDC Director Thomas Frieden, MD, MPH, claimed recently but partly is the result of outside pressures to prescribe these drugs.

"It bothers me that Dr Frieden calls this a 'doctor driven epidemic'," said a pain management specialist. "Big Pharma's push for profits by aggressively marketing opioids such as OxyContin is also a driving factor.  The push that pain is the fifth vital sign and that we can achieve pain free life drives this as well.  The policies of the government that drive a vision of healthcare where patients are customers to be satisfied and tying payments to satisfaction surveys drives this.

"Doctors bear our share of responsibility, but this national crisis has many authors," the specialist said.

The full results of the Medscape poll are available here.

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