The Importance Of Patient-Centric Opioid Prescribing Guidelines – forbes.com – by Joshua Cohen – Aug 2017
In light of an opioid crisis that has claimed tens of thousands of lives, health authorities and regulators have attempted to reduce the number of opioids prescribed to patients by forced tapering or the institution of quotas.
While the U.S. Centers for Disease Control and Prevention (CDC) advocates tapering and, in some cases, discontinuing opioids in patients who have used using them as long-term therapy for non-malignant chronic pain, it purposely designed its guideline as non-mandatory
Guidelines are, by definition, not mandatory; they are simply guidelines, however…
They can be used to make rules establishing their suggestions as absolutes. I’m sure the guideline authors (mostly PROP members) knew this is exactly what would happen with opioid prescribing.
Additionally, it absolves them of guilt for the atrocities inflicted on chronic pain patients in the name of their “non-mandatory” guidelines, which have predictably been weaponized as hard limits on dosages.
However, a number of legislators, pharmacies, and payers have perhaps misinterpreted the recommendations and turned them into compulsory limits and quotas.
In certain instances, mandatory opioid tapers may do more harm than good, medical experts warn in a letter published in the journal Pain Medicine.
The letter states that “rapid forced tapering can
- destabilize patients,
- lead to a worsening of pain,
- precipitate severe opioid withdrawal symptoms and
- cause a profound loss of function.”
Obviously, reducing misuse is an appropriate objective. But, the means to do so ought to reflect a balanced approach of risk management, rather than blunt instruments, such as a blanket policy of compulsory tapering or the institution of mandatory opioid quotas.
…according to Dr. Joanna Starrels, an opioids researcher and associate professor at the Albert Einstein College of Medicine “the decision to taper opioids should be based on whether the benefits for pain and function outweigh the harm for that patient.”
A case-by-case approach is warranted, she says, as each decision “takes a lot of clinical judgment. It’s individualized and nuanced.
We can’t codify it with an arbitrary threshold.”
But that’s exactly what has happened in this country, despite the CDC’s insistence to the contrary: Opioid Guidelines Not a Rule, Regulation or Law.
And it’s not even addressing the problem it is intended to rectify:
According to Dr. Marcia Angell, the “overwhelming majority of deaths are caused not by opioids such as OxyContin, but by combinations of fentanyl, heroin, and cocaine. … frequently taken along with benzodiazepines and alcohol.”
The letter published in Pain Medicine calls for a patient-centered approach of “compassionate systems for opioid tapering” in carefully selected patients, with close monitoring and realistic goal
Notably, in 2016, the CDC laid the groundwork for risk stratification in its guidelines on opioid prescribing. In that guidance, the CDC outlined a nuanced, patient-centric view on opioid prescribing.
Namely, patients who present at the physician’s office with chronic pain should be assessed individually for their actual need for opioids versus non-opioid or even non-pharmacologic treatment, as well as key factors gleaned from a patient’s risk profile.
In other words, rather than automatically matching pain levels to specific doses of an opioid or other analgesic, physicians are advised in the CDC guideline to tailor treatment following a thorough evaluation of each patient that includes a review of tolerance for pain, subjective preferences for treatment, and risk of misuse, abuse, and diversion.
So why isn’t anyone enforcing this part of the guideline?
Forced tapers across the board go directly against this stated guideline to “tailor treatment following a thorough evaluation of each patient”, but no one is pushing for such individualized treatment.
Nor are they pointing out that the guideline was intended ONLY for primary care physicians and ONLY for initiating new opioid therapy.
Nor is the CDC doing what they said they would: studying and evaluating the outcomes of this bomb they dropped.