The Pendulum Has Swung Too Far

Treating Pain in Primary Care

Linda Brookes, MSc

Disclosures

February 22, 2019

In This Article

Responding to the CDC Guideline

In November 2018, the AMA passed a number of resolutions critical of the CDC guideline. One expressed support for the use of opioids at greater dosages than 90 MME/day in some patients with acute or chronic pain, asserting that "such care may be medically necessary and appropriate." Another resolution protested that "the misapplication of the CDC guideline by pharmacists, health insurers, pharmacy benefit managers, legislatures, and governmental and private regulatory bodies in ways that prevent or limit access to opioid analgesia."

The AMA also resolved that physicians should not be subject to "professional discipline, loss of board certification, loss of clinical privileges, criminal prosecution, civil liability, or other penalties or practice limitations" solely for prescribing opioids above the CDC-recommended threshold. "Kudos to the AMA for coming forward at this point, although 2 years into the process," Reid commented.

Doctors who prescribe opioids... can find their practices under investigation by government agencies or state medical boards.

The following month, a federal advisory panel, the Pain Management Best Practices Inter-Agency Task Force, criticized the CDC guideline in a draft report, also noting that it "was not intended to be model legislation for state legislators to enact." The task force also pointed to the lack of attention paid in the guideline to the need to identify the cause of pain and "the biopsychosocial mechanisms that contribute to its severity and associated disability."

Since 2016, a number of other US guidelines[26,27,28] on treatment of chronic pain with opioid medication have appeared, "but they all contradict each other," Fox maintains. New guidelines have been called for, specifically by FDA Commissioner, Scott Gottlieb, MD, who suggested the development of a "professional guideline" by societies working with the FDA.

More recently, the same federal task force proposed an update of the CDC guideline incorporating new scientific evidence, stressing the need for pain management guidelines specifically focused on older adults, taking into account their unique risk factors, and emphasizing 'a multidisciplinary approach with a nonpharmacologic emphasis." The task force draft report is available for public comment through March 2019, after which it must be finalized and submitted to Congress before any action can be taken.

Is Regulation Getting in the Way of Treatment?

Most states have now set limits on first-time opioid prescriptions, with a limit on the number of days that may be supplied (typically 5-7); there are some exemptions for cancer and palliative care patients. Prescription drug monitoring programs have been established and state medical board regulations intensified for oversight of physicians who prescribe opioids. Health plans, pharmacy benefit managers, and pharmacies have also applied their own restrictions.

Sometimes a law can be counterintuitive, noted Harvey Hsu, MD, from the University of Arizona College of Medicine, Phoenix. "I have a patient with severe spinal stenosis who uses oxycodone when the pain worsens. He only needs it a few times a year, so he only needs to refill it every few months," Hsu recounted. "Under the new law, the pharmacy classifies it as a new prescription each time, and the pharmacy gives him only 5 days of medication, so 10 pills. If he refilled it every month, he could pick up 30 pills and there would be no issue. In this case, there is an incentive for the patient to use the medications more frequently, so that he gets the full 30 pills with each prescription."

Despite data showing that overdose deaths are primarily caused by illicit opioids, current federal enforcement efforts are focused on opioid prescribing. In 2018, President Trump launched the Initiative to Stop Opioids Abuse and Reduce Drug Supply and Demand. The effort aimed to lower opioid prescriptions by one third within 3 years. As part of the plan, the Drug Enforcement Administration announced its intention to decrease 2019 manufacturing quotas by 10% for the six "most frequently misused opioids" (oxycodone, hydrocodone, oxymorphone, hydromorphone, morphine, and fentanyl). Critics pointed out those previous decreases in opioid production quotas had resulted in shortages that interfered with patients' treatment, a risk that the department acknowledged. Then Attorney General Jeff Sessions suggested that aspirin might be a reasonable substitute for opioids.

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