Are the CDC Opioid Prescribing Guidelines Realistic?

Are the CDC Guidelines on Opioid Prescribing Realistic?MedPage Today – 09/07/2016 – By Cheryl Zigrand

The CDC guidelines recommend nonpharmacologic and nonopioid pharmacologic therapy as the preferred options for treating chronic pain. In addition, they emphasize that it is important to establish realistic treatment goals and discuss the benefits and risks before initiating therapy.

Real-World Limitations

The gray areas and complexities of individual pain management make it difficult to follow strict treatment modalities, which causes clinicians to shy away from opioids for fear of potential medicolegal or licensing implications, as well as the inconvenience and added time associated with additional documentation requirements  

“Some of the recommendations on dose limits are fairly arbitrary:

…while they are just ‘recommendations,’ payers and even lawyers will likely interpret them as strict limits,” said Daniel P. Alford, MD, MPH, Associate Professor of Medicine and Director of the Safe and Competent Opioid Prescribing Education Program at the Boston University School of Medicine and Boston Medical Center.

Patients are forced to “doctor shop” to find a clinician who will prescribe their opioids, or, worse, self-medicate with illicit drugs. Although Dowell says the CDC recommendations are meant to be “voluntary, rather than prescriptive standards,” clinicians remain concerned about using these treatments.

Access issues also present challenges to taking advantage of the nonpharmacologic options preferred by the guidelines

“There is a lack of access to nonpharmacological comprehensive pain management programs,” said Alford.

“Our reimbursement system favors the use of medications for managing chronic pain.

Potentially important but costly nonpharmacological pain management options, such as acupuncture or massage therapy, are rarely covered by insurance.

“I can guarantee you with 100% certainty that if comprehensive pain management programs sprouted up, opioid prescribing would dramatically decrease and patients would get their pain managed,” said Alford.

When developing their guidelines, the CDC was fully aware of such limitations in access and insurance coverage, and acknowledged the reality with recommendations for low-cost alternatives for such nonpharmacologic therapeutic options as exercise therapy

Importantly, because the CDC is aware of the very real barriers to therapy, “the CDC is committed to working with federal partners and payers to evaluate strategies, such as payment reform and healthcare delivery models that could improve patient health and safety,” she said.

It still makes no sense to restrict opioids before any other effective interventions are available and accessible.

Education and Evidence Are Key

“A more fine-tuned solution would be educating clinicians how to make treatment decisions based on an individual patient’s risk and benefit,”

“Education takes time and changing practice takes time.” The CDC guidelines are an appropriate place to start.

“The best way to achieve a reasonable balance is to ensure that decisions about opioid use are informed by the best available evidence on benefits and harms of opioids as well as by individual clinical circumstances,” says Dowell

“There is a responsibility when you become a physician or nurse practitioner or physician assistant that you manage chronic pain,” says Alford. “And that means that some of your patients who may benefit from opioids should have access to them, and you should be confident in your ability to prescribe them in a safe way.”

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