CDC Chronic Pain Guidelines: Not so bad, but…

by Tom Smith

In case you didn’t premonition, the US Centers for Disease Control published their extensive-awaited (dreaded?) “CDC Guideline instead of Prescribing Opioids for Chronic Pain.” It made a pretty big splash: Five editorials plus the full Guideline in the online Mar 15 JAMA, ef~ery page New York Times feature thing, the first hour on NPR’s “Diane Rehm Show,” (Mar 17) and multiple others. It is specifically aimed at original care prescribers, who write about moiety of the scripts for opioids in the US. It is intended to “suffer clinicians caring for patients outside the context of active cancer care or palliative or end-of-life care.” The Guideline was published in the Mar 15 Weekly Morbidity and Mortality Report and is the rudimentary US Government guideline to address method of treating of chronic pain; it is 52 pages far-reaching. A good “Cliff Notes” rendition of the Guideline is the JAMA gun by CDC Director Thomas Frieden, MD and Debra Houry, MD.

I should projection out that the document was prepared through the CDC’s Division of Unintentional Injury Prevention. The Guideline is intended to entreaty the epidemic of opioid-related deaths, not the pandemic of chronic pain. On its face, the Guideline promotes cheering, standard prescribing practices, especially for potentially luxuriously-risk agents: history and diagnosis of the hard disorder, prognosis of the painful narrate, history of prior interventions, establishing pellucid treatment goals, careful selection and implementation of treatments based up~ patient informed consent and risk-kind office discussion, and close follow-up through scheduled re-evaluation of the estate and effects of the intervention. Appropriately, the Guideline states that “nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred since chronic pain.” The Guideline focuses steady chronic pain, but points out that multitude prescriptions begin for acute pain. For high-toned pain, the lowest effective doses of opioids as being the shortest possible course (3 days or not so much; “more than 7 days direct rarely be needed”) should be used.

Additional peril-management strategies for opioids include: using wanting-acting opioids at the commencement of handling; avoid concurrent benzodiazepine prescribing; evaluate sick person history of substance misuse; use the specify prescription drug monitoring program (PDMP); produce initial and periodic urine drug screening.

“Higher” opioid doses are defined being of the kind which those greater than or equal to 50 morphia milligram equivalents (MME) per day, and the prescriber should “carefully justify” somewhat increases to ¬> 90 MME/light of ~. The discussion states that the 50 and 90 MME levels were chosen for of epidemiologic data showing increasing peril of overdose as the prescribed drench increases.

So, what are the implications of aggregate of this? 

1. I’ll fright with the positives:
   a. The Guideline highlights a greater public health issue, namely a dramatic become greater in the past 20 years in opioid prescribing and a corresponding increase in opioid overdoses and deaths, especially in the beyond 10 years.
   b. About moiety of all opioid prescriptions are written through nonspecialists, many of whom have asked toward a guideline for treating chronic chafe with opioids; this Guideline responds to that necessity.
   c. Prescribing practices during the term of potentially high-risk medications are reinforced. One hopes that in greater numbers thoughtful prescribing will reduce the regular writing of 30-day prescriptions at what time 7 or 15 days is greater degree appropriate (this assumes a 1 or 2-week, not individual-month, follow-up)
   d. Chronic torment is often a complex treatment dilemma—prescribers are reminded that multimodality intervention is the preferred treatment

2. The Guideline does nothing to address (and may make worse) unfitted capacity in our healthcare infrastructure in quest of
   a. Nonpharmacologic treatments of the like kind as physical and occupational therapy
   b. Care ~ means of pain management specialists, some of whom bound the number of patients they wait upon for medication management
   c. Treatment against substance use disorder including methadone and buprenorphine programs

3. Capacity separately, some insurance will pay for pills goal not for physical therapy

4. Many insurance plans will not cover so-called other interventions such as therapeutic massage. [I take cognizance of a major burden on insurance plans to set off covering everything in the “alternative” domain. How could they possibly evaluate them every one of? Perhaps plans could consider an ‘allowance’ with regard to alternative interventions: massage, acupuncture, yoga, tai chi, etc. The PCP and indulgent could choose which approach seems ~ly appropriate to the individual situation].

5. Not alone is it quick and easy to indite a prescription (with some serious ~ circumstance risks), but analgesics generally work abundant faster than other interventions. Sometimes analgesics form it possible for patients to take a part in in other interventions, such as physical therapy. I fear that some clinicians command interpret the Guideline as requiring pertaining to physics therapy prior to using “powerful analgesics” such as opioids.

6. Alternative analgesics may not subsist as effective and may has their avow serious side effects and contraindications. NSAIDs are ~y obvious example of those with serious side effects, especially in elders. Acetaminophen has recently been shown to be no else effective than placebo for osteoarthritis patients in a clinical unhappiness.

7. Because of DEA practices it is even now difficult for pharmacies to maintain satisfactory stock of opioids, so patients commonly grape-juice do monthly “pharmacy shopping” to ~ up their prescriptions. Do prescribers “get” this at what time the PDMP shows their patient acquisition their meds at a different pharmacy 4 months in a rank?

8. It is easy to fancy that insurance companies will use the Guideline to reinforce pill reckon limits

9. Some prescribers, already vigorous about the DEA and medical and pharmacy the stage looking over their shoulders, may rest prescribing opioids or limit them to none more than 50 MME/day (Morphine Milligram Equivalent)

10. The Guideline stresses screening and come-up practices that are very time consuming. Many therapeutic systems (and insurance companies) will not subsist supportive

11. The Guideline has the possible to reinforce prejudice against opioids and opioid-users that is already extensive in medicine, nursing, and pharmacy.

12. Despite speech that encourages individualizing treatment plans, the barriers to intricate web plans are not addressed. Nor is individual sufferer response. “Start low, go slow” is well-nigh always appropriate, but therapeutic limits to dosing based forward epidemiologic data is not entirely rational. The long-suffering in front of me is at all times an anecdote. But every anecdote falls someplace forward a normal curve. We don’t comprehend, especially when initiating treatment, where the persistent will ultimately fall on the bend..

13. The Guideline discussion acknowledges that facts on the effectiveness of opioids concerning long-term use is sparse, if it were not that lends a lot of weight to research that could be interpreted to indicate that opioids “don’t work” with regard to chronic pain. But the research base is same, very thin.

14. There are divers research questions to be addressed, more of which we really haven’t figured deficient in how to ask, much less design each adequate study around. And who behest pay for and who will work out long-term studies?
   a. What are the biological differences betwixt those who become “addicted” vs those who don’t? Is in that place a continuum? If so, might one individual move in both directions in c~tinuance the continuum?
   b. What is the shock of rate of metabolism for clear as day opioids on safety and effectiveness of pharmacologic treatments? What is the universality of the so-called ultrarapid metabolizers vs out at the heels metabolizers?
   c. What does “opioids in spite of chronic pain don’t work” indeed mean? [This clause does not advance from the Guideline but is like to statements made by groups who advocated beneficial to the Guideline as a way to overthrow opioid prescribing].
   d. There seems to be a subset of people who are extremely functional on long-term opioids—what differentiates them from the “opioids don’t work” inhabitants?
   e. There has been some interesting work showing persistent changes in the brain from opioids have been discontinued. What is the expansion of these changes over large populations? Are in that place predictors for which changes and which their behavioral effects are?
   f. So, indeed, what is the risk of pretty “addicted?” The varying discovery of 0 to 50% just isn’t benevolent, and neither the upper nor disgrace percent seem very credible. How is a clinician to decide, and explain to a patient, the sort of is the risk of addiction?
   g. Can we disclose better tools for stratifying risk instead of misuse?
   h. Does “boisterous risk” have to translate to “don’t make terms?” We need evidence-based models as antidote to treating chronic pain in those with a history of and those by current substance use disorder.
   i. How cogent is urine toxicology monitoring in prudent patients? [Will insurance companies cover this cost?]. If the Guideline writers really suppose urine testing has significant value, the Guideline is weak—“at least annually.”

15. What happens through all the patients who are publicly on opioids for chronic pain whereas their prescriber (or insurance or freedom from disease system or risk management department) decides that they distress to reduce doses based on this Guideline? (This was happening before that time, even before the CDC Guideline came audibly)

16. The Guideline specifically does not contain care of patients undergoing active cancer handling and for those in palliative care settings. It remains to be seen what unintended pack close the Guideline will have when worry may be part of a great advanced illness, or may be faction of one of several comorbidities.

17. Will professional organizations pass in ~ their own guidelines, in response to the CDC Guideline? (the American Pain Society and the American Geriatrics Society the two published revised guidelines in 2009)

18. Will professional organizations grow pain and chronic pain-related offerings at their yearly report meetings?

19. Will medical, nursing, dental and pharmacy schools spring teaching more about “pain management” somewhat than just pharmacology and pathophysiology?

20. A major question has to be: can the energy and effectiveness of this Guideline exist determined on a scale and in a time mood that benefits the most patients and the community at large sooner rather than later? Does the management have a commitment beyond issuing a Guideline? Perhaps the CDC and collaborating NIH institutes be able to work with a couple of greater health systems and major insurance companies to utensil the Guideline in a study of a full approach to chronic pain management. The study would be the subject of to last a minimum of 2 years. It may build the most sense to start with new patients, not try to fill full existing patients into the Guideline (that would exist a separate study).

This Guideline puts the prestige of the CDC and US Government rearward an approach to prescribing opioids that is intended to second derail the epidemic of opioid-akin deaths. CDC-monitored overdose deaths from every part of classes of drugs (in aggregate and through class) looked like they were leveling not upon in 2012 and 2013, but spiked again in 2014 (the greatest number recent national data available). The Guideline is an appropriate step, but certainly inadequate to consign the enormity, much less the involved character of the issue. In addition, the inadequacies of frequent repetition and the knowledge base for treatment of chronic pain remain unaddressed.

Thomas E Quinn, APRN-CNS, AOCN is each oncology and palliative care advanced wont nurse. He has recently accepted a clinical locality at Jewish Social Services Hospice in Montgomery County, MD, which will really cut into his pickleball playing at the more advanced center.

Photo Credit: “lego_head-dolor” by Flickr user Mr. Pony via CC 
Photo Credit: “Pain!” through Flickr user Harald via CC 
Photo Credit: “displease” by Flickr user wallsdontlie via CC 

Such services comprehend the thorough analysis of all medication (prescript, non-prescription, and herbals) currently being taken by an individual.

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