CDC guideline comment by Terri Lewis

My Comments on CDC’s Proposed Guidelines for Opioid Prescribing | Terri A. Lewis | LinkedIn | Terri A. Lewis | Dec 30, 2015

While CDC’s CORE expert group made it their mission to review:

  • when to initiate or continue opioids for chronic pain;
  • opioid selection, dosage, duration, follow-up, and discontinuation;
  • assessment of risk and
  • harms of opioid use,

there are a number of fundamental but key issues that remain unaddressed.

First, while addressing the contextual information there is almost no address of three important issues

  1. the nature of chronic pain and its variations,
  2. the nature of patients and their variations in the expression of pain and response to treatment,
  3. the definitions that have been applied for the terms associated with opioid use disorder (e.g., abuse, dependence, addiction).

How can one even begin to address the issue of selection of any methodology without addressing these topics? 

Second, repeated references throughout the document make it clear how the experts feel about how poorly informed physicians are – so much so, that they cannot hold a conversation with patients to counsel them about the impact of opiates as prescribed. Yet nowhere does the conversation address the need to provide physicians with the necessary training to inform their prescribing practices and assure monitoring for benefits or harms.

Third, by its’ very nature, chronic pain is a unique disease state and its presence indicates that something has broken of some proportion to disrupt the body system conditions of homeostasis and return to normal. At this point, for some conditions, there may be treatment improvement, but for most management is defined in terms of functional interaction with the consumer’s environments and daily demands of life.

We do not yet know how to cure chronic pain, which occurs along a continuum from less extreme to most extreme and disruptive. This working document fails to acknowledge this fact, which may be one reason why our expectations for the use of opioids regulated by people who don’t know us causes us so much concern and disappointment in those tasked to lead.

The entire discussion is built on a scaffold of the medical model – a model which fails to recognize anything other than treatment which is measured in cure, and the requirement that good patients conform and adhere to recommendations. One assumes that in this model, the physician will offer treatment that will improve and when it does not, then either the physician or the patient is responsible for failure to progress.

Chronic pain does not cure, so looking for an arbitrary 30% standard for improvement after initiation of opioid prescribing just might be entirely the wrong metric. And the medical model does not account for the functional disability imposed by chronic pain.

The term opioid use disorder is defined in the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) as a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period (http://emedicine.medscape.com/article/287790-clinical).

  • Taking larger amounts of opioids or taking opioids over a longer period than was intended.
  • Experiencing a persistent desire for the opioid or engaging in unsuccessful efforts to cut down or control opioid use.
  • Spending a great deal of time in activities necessary to obtain, use, or recover from the effects of the opioid.
  • Craving, or a strong desire or urge to use opioids.
  • Using opioids in a fashion that results in a failure to fulfill major role obligations at work, school, or home.
  • Continuing to use opioids despite experiencing persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  • Giving up or reducing important social, occupational, or recreational activities because of opioid use.
  • Continuing to use opioids in situations in which it is physically hazardous.
  • Continuing to use opioids despite knowledge of having persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by the substance.
  • Tolerance, as defined by either a need for markedly increased amounts of opioids to achieve intoxications or desired effect, or a markedly diminished effect with continued use of the same amount of an opioid.
  • Withdrawal, as manifested by either the characteristic opioid withdrawal syndrome, or taking opioids to relieve or avoid withdrawal symptoms.

This description misrepresents the experience of persons with chronic pain who have pain generating syndromes that have lasted more than 3 months and which are expected to be present at their death.

While DSM-V demands that we intervene and treat opioid use disorder as an aberration of behavior, (a substance use disorder), for the person with chronic pain, the focus is quite different.

Indeed, this description in DSM-V acknowledges this difference and states clearly that:

“Addiction must be defined by the observation of maladaptive behaviors, such as adverse consequences due to drug use, loss of control over drug use, and preoccupation with obtaining opioids, rather than pharmacological phenomenon of physiologic dependence, tolerance, and dose escalation. Do not use the term addiction to describe patients who are merely physically dependent. Also, keep in mind that undertreatment in patients with pain may result in a pseudoaddiction, and opioid-seeking behavior may be mistaken for addiction.”

And the desire to achieve a quality of life in the face of an unfixable illness or injury is not in and of itself, aberrant behavior but rather an adaptive behavior.

After an examination of five questions derived from the AHRQ study plus one more, the CORE working group of ‘experts’ seems to have settled on this:

  • The evidence here is very low – too low to be conclusive as others have observed. More understanding (research?) is required.
  • Patient characteristics and physician prescribing practices vary considerably. This has great impact on patient selection into treatment protocols. When in doubt, treat everyone the same.
  • The comparative effectiveness of opioid dosing strategies can be addressed by recommending that one always starts with and stays with the lowest dose possible or no more than 90 MED.
  • The accuracy of existing instruments for predicting risk for opioid overdose, addiction, abuse, or misuse doesn’t exist, or not in any way that we understand for persons with chronic pain. A urine tox screen provides no direction for treatment nor is it a substitute for education and counseling. Reliability and validity are questionable at best.
    Among the useful emergent tools is the CYP450 panel which can provide the primary care physician and the patient some direction for navigating prescribing decisions and the path through comorbidities that occur with chronic pain – anxiety, depression, PTSD.
    Yet it is never mentioned, nor is the need to treat each patient as an individual, unique in their injury and recovery-a primary tenet of the practice of medicine.
  • The ethical implications of all of this seem to have been set aside. I wonder why?

Persons with chronic pain are at risk – of misdiagnosis, under treatment, and mistreatment as the DSM-V points out. Among the most vulnerable of patients, they are predated upon regularly by unscrupulous members of the health care profession.   

 

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