The recent issuance of draft guidelines for opioid prescribing by the Centers for Disease Control and Prevention (CDC) posits some troubling guidelines for physicians – troubling because they prioritize the practice of prescribing over the treatment of patients.
They infer that the use of opioids is tantamount to the onset of addiction and equate dosing levels with metrics unrelated to a patient resuming activities of daily living.
To ignore the individual patient’s needs in favor of applied population modeling for prescription overdose is tantamount to the institutionalization of malpractice and violates the very tenets of person-centered health care.
Physicians are moving to an environment that will redefine and reclassify conditions associated with chronic pain based on a body systems approach. In the arena of musculoskeletal systems alone, there are 99 classifications associated with pain levels that range from acute to chronic to intractable.
All have the potential to require lifetime treatment at levels beyond those associated with acute pain.
A review of death and injury data maintained by the CDC indicates that prescription drug overdose is not even in the top 15 leading causes of death in the U.S. The number of overdoses that occur in the population annually should not be the primary filter through which we consider the needs of persons with chronic pain.
The third largest measured harm to patients is associated with care by a physician or hospital – conditions over which patients have no control and which can result in lifetime injury. Wrong diagnosis, wrong prescribing, failure to rescue, hospital acquired infections, improper surgeries and other forms of malpractice all create conditions of significant injury that can lead to chronic pain.
Far more risk to the patient is associated with covering up harmful industry practices and the institutionalization of biases that opiod treatment causes addiction.
Correlation is not causation.
Why is this basic statistical rule so frequently overlooked by medical people who have been trained in these matters?
The important question is not whether opioids are contraindicated by regulation, but whether opioids are likely to return the patient to a state of functional behavior or have a role in helping them maintain their independence and daily activities.
The CDC’s recommendation that 3 days or less supply of prescribed opioids for non-traumatic acute pain may well fall short of individual needs.
Patient contracts are ethically troublesome and tantamount to withholding medications based on characteristics or behaviors that may have nothing to do with patient outcomes.
It is unethical to hold a person in chronic pain hostage to the withholding of effective treatment, and many believe this should not be the basis for informed consent conversations
Another one of the CDC’s recommendations is for urine drug testing of patients on long term opioid therapy. Urinalysis often falls far short as a metric for adherence and compliance with a prescribing routine. Differences in individual rates of metabolism may well cause providers to make errors of judgment when analyzing drug test results. Many urine tests have significant rates of poor performance, physicians may not understand the potential for false positives and negatives, and some labs fail to employ procedures that are consistent.
These tests also have the potential to add many hundreds of dollars to the patient’s bill, a cost for which they cannot be reimbursed on many insurance plans.
Failing a drug test may unnecessarily stigmatize the patient and impair the treating relationship.
Risks and Benefits of Opioids
Most providers are now required to review the patient’s history of controlled substance prescriptions by using prescription drug monitoring databases to determine whether the patient has access to excessive opioid dosages or dangerous combinations of medications. Used properly, this is an effective tool. But it is important for providers to understand that this data itself has limitations and may be biased by the availability of medications, prescriber behavior practices, and pharmacy filling practices.
Many a user has been accused of abuse for data that reflects limitations that have nothing to do with the patient. Providers should be very careful about drawing conclusions and should balance this information with other indicators – patient reports, community supports, consumer functioning, and so forth.
Chronic pain is a total body experience, no matter the origin of the injury or illness.
The person is not going to be “cured” and cure is not the treatment goal.
Returning the person to the best function possible is the goal, along with assuring them that you will be a partner in helping them achieve a quality of life through treatment they can depend on.
We have to change our thinking about approaches that require us to treat to the dose, and stop interpreting this issue of pain care within the acute care model. Those who would divert us from this goal are not leading the public conversation toward an effective national pain strategy.
Author: Terri Lewis, PhD, is a specialist in Rehabilitation practice and teaches in the field of Allied Health. She is the daughter and mother of persons who have lived with chronic pain.