Chronic Pain Opioid Guidelines Updated for State Medical Boards

Nancy A. Melville

June 14, 2017

The Federation of State Medical Boards (FSMB) has updated its guidelines on the use of opioids in the treatment of chronic pain, with new policies underscoring the need for physicians to be proactive in helping to turn the tide of the nation's opioid epidemic.

"The FSMB workgroup worked diligently to identify a number of specific areas that could be updated to more closely align with recent advisories issued by the Centers for Disease Control and Prevention [CDC] and the US Food and Drug Administration [FDA], as well as the current science for treating chronic pain with opioid analgesics," Humayun Chaudhry, DO, president and CEO of the FSMB, told Medscape Medical News.

Among the key misconceptions among clinicians in the prescribing of opioids for chronic pain is the realistic goal of pain management with extended-release or long-acting opioids, which should not necessarily be to eliminate pain altogether but to provide enough pain control to allow for the ability to carry on with daily activities, Dr Chaudhry said.

"The elimination of pain is not always practical or achievable, especially in patients who have incurable and permanent neurological damage or injury."

"That is why the FSMB and other organizations recommend that physicians establish goals and objectives of an opioid treatment plan that are discussed with the patient and his or her family or caregiver and documented in the patient's medical record," he explained.

While the updated guidelines address a broad range of issues on the use of opioids for chronic pain management, Dr Chaudhry outlined some of the key changes: 

  • Patient assessments and evaluation :  "We updated the section on patient evaluation to include a recommendation that assessment of the patient's personal and family history of mental health disorders should be part of the initial evaluation, and ideally should be completed prior to a decision as to whether to prescribe opioid analgesics," Dr Chaudhry said. "All patients should also be screened for depression and other mental health disorders, as part of risk evaluation."

  • Treatment agreements: The updated guidelines recommend written informed consent and use of a treatment agreement. "We updated the definition of treatment agreements which outline the joint responsibilities of the clinician and patient, including the patient's agreement to periodic and unannounced drug testing for opioids and other medications with potential for substance use disorder as well as permission to query the state's prescription drug monitoring program (PDMP)."

  • PDMPs: "We updated language strongly recommending that the state PDMP be consulted prior to initiating opioid therapy and at appropriate intervals thereafter to determine whether the patient is receiving prescriptions from any other clinicians, and the results obtained from the PDMP should be reviewed," Dr Chaudhry said.

  • Decision to initiate and discontinue opioid therapy: "We added language recommending that nonopioid and nonpharmacologic treatments should be considered before starting opioid therapy for chronic or acute pain lasting beyond the expected duration," Dr Chaudhry said. Language was added to acknowledge that discontinuing or tapering of opioid therapy may be required for many reasons, and, ideally, clinicians will have an exit strategy for patients receiving opioids at the outset of treatment.  Dr Chaudhry noted that reasons for discontinuing opioid therapy include resolution of the underlying painful condition, emergence of intolerable side effects, inadequate analgesic effect, failure to improve the patient's quality of life despite reasonable titration, failure to achieve expected pain relief or functional improvement, failure to adhere to the treatment agreement, or significant aberrant medication use, including signs of addiction. "Additionally, clinicians should not continue opioid treatment unless the patient has received a benefit, including demonstrated functional improvement," he said.

  • Concurrent use of benzodiazepines: Language was added to clarify that the concurrent use of benzodiazepines and opioids, recently added as a Black Box warning by the FDA, greatly increases the risk for adverse events, including addiction and death. "Given this increased risk, clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible," Dr Chaudhry said.

  • Prescribing naloxone and methadone: Language was added stating that before prescribing methadone for its analgesic effect, it is strongly recommended that clinicians have specific training and/or experience because individual responses to methadone vary widely, increasing the risk for overdose. "It was also recommended that clinicians should consider prescribing naloxone for home use for all patients with opioid prescriptions in case of accidental or intentional overdose by the patient or household contacts," Dr Chaudhry added.

Opioid prescribing trends have shown some encouraging patterns, with the CDC reporting at the end of 2016 a slowing of the increase in deaths from abuse, misuse, and diversion of prescription opioids in 2014 to 2015 (2.6%), compared with an increase from 2013 to 2014.

"We would like to think that this is due to prescribers' greater awareness of the opioid epidemic and ways to mitigate against it," Dr Chaudhry said.

"On the other hand, death rates for synthetic opioids other than methadone increased 72.2% from 2014 to 2015, and heroin death rates increased 20.6%."

He noted that both of the increases in death from illicit opioids occurred across all age groups 15 years and older, in both sexes, and among all races and ethnicities.

"All of this highlights the continued need for public health, state and federal regulators, and law enforcement to work together."   

In commenting for Medscape Medical News, Ed Michna, MD, JD, from Brigham & Women's Hospital and Harvard Medical School and director of the Pain Trial Center, in Boston, Massachusetts, who previously served on the board of the American Pain Society, said the guidelines allow for a needed emphasis on personalized care.

"I think the guidelines are well done and rational," he said. "They have inclusions for different populations and they talk about flexibility in the individualization of care, which is really what we should be doing."

While many states have enacted more specific policies and restrictions on opioid prescribing, Dr Michna said flexible guidelines help to avoid the unintended consequences of such restrictions.

"I agree with the more general guideline approach because when you get down to specifics, you may start impeding on the practice of medicine and the ability to provide individualized care based on the best evidence."

Dr Michna disclosed that he has previously consulted and performed funded research for most pharmaceutical companies in pain medicine but currently has no relationships.

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