Hello, everyone. I'm Dr Kenny Lin, a family physician at Georgetown University Medical Center in Washington, DC, and I blog at Common Sense Family Doctor.
The 2016 guideline on prescribing opioids for chronic non-cancer pain from the Centers for Disease Control and Prevention (CDC), which I discussed in a previous Medscape commentary, recommends that clinicians "should avoid increasing dosage to greater than or equal to 90 morphine milligram equivalents (MME) per day or carefully justify a decision to titrate dosage" to that level. For the most part, my clinical practice has been consistent with this recommendation. I can count on one hand the number of patients I have started on opioids for chronic pain conditions who are taking daily doses that approach or exceed the CDC's guideline threshold.
However, since the guideline's publication, I have inherited increasing numbers of patients who have taken high doses of opioids for years, and whose previous primary care or pain management physicians decided to either stop prescribing opioids over the 90-MME-per-day threshold or stop prescribing these drugs altogether. Although a systematic review of very low-quality evidence found that gradually tapering off high doses of opioids without worsening patients' pain or quality of life is possible, neither this review nor the CDC guideline supported involuntary tapering. But a recent commentary in the New England Journal of Medicine suggested that forced tapering of opioids is occurring more often, as some primary care clinicians move to "no opioid" policies and others decline to take on new patients with preexisting prescriptions.
For my patients who have chosen not to taper their doses, it is becoming more difficult to fill their prescriptions. Even in the absence of any evidence of opioid use disorder, pharmacies are turning them away based on the CDC guideline limit. I have been receiving sternly worded letters from their insurance plans, citing the CDC guideline and creating administrative obstacles to continued opioid prescribing. This included, in one case, a requirement to obtain a new prior authorization every month for opioids in a patient who had extensive documentation of his pain condition and had never raised any red flags for abuse or diversion.
Since 2016, many states have enacted arbitrary restrictions on daily pill counts or the length of opioid prescriptions. The Centers for Medicare & Medicaid Services recently proposed to deny coverage for more than 7 days of opioid prescriptions equal to or greater than 90 MME daily in a draft regulation that was opposed by many pain experts, including some authors of the CDC guideline.
Our country is paying a high price for the medical profession's mistaken belief, with the encouragement of pharmaceutical companies, that we could eliminate chronic pain with enough opioid prescribing. But as researchers have previously pointed out, the evidence that restrictions on the quantity or duration of legal opioid prescribing reduce the incidence of opioid use disorder and overdose deaths is limited to nonexistent. Instead, I fear that recent "pill limit" policies to address the opioid epidemic will lead to a great deal of unintended and unnecessary suffering in patients with chronic pain.
If big pharmacy chains, health insurers, and state and national legislators want to help family physicians make a serious dent in the opioid epidemic, they should stop misinterpreting the CDC guideline. Instead, provide us with the time, systems and resources necessary to identify and treat opioid use disorder in high-risk patients. And remove bureaucratic and logistical barriers to offering or referring appropriate patients for buprenorphine medication-assisted treatment.
This has been Dr Kenny Lin for Medscape Family Medicine. Thank you for listening.
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Cite this: Limiting Opioid Prescribing: The Fallout From Rules Telling Doctors How to Prescribe - Medscape - May 08, 2018.