A panel of experts addressed several challenges associated with the implementation of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain in a report published in Pain Medicine. Topics covered included recommended dosage ceilings and durations, opioid tapering, and availability of multimodal pain care.
The multidisciplinary panel of physician experts convened by the American Academy of Pain Medicine Foundation largely agreed with the CDC’s efforts to reduce over-prescription of opioids as formulated in the guideline. The panel identified several challenges to widespread and uniform guideline implementation and issued recommendations to clarify the guideline to avoid misapplication and inflexibility.
Most physicians are unsure whether daily opioid dosage ceilings and prescription duration recommended by the CDC guideline should be universally applied regardless of previous opioid exposure, according to the panel. Strictly enforced ceilings may promote abrupt dose reductions in patients on high doses of opioids, which might lead to withdrawal symptoms, hyperalgesia, and dangerous self-medication. Thus, the experts advocated for the development of validated tapering protocols, which would include the patient in the decision-making process; further research on optimal dosage thresholds; and policies allowing for provisions for patients who need and benefit from higher dosages or longer prescription duration.
The panel also addressed the lack of accessibility and coverage for comprehensive and multimodal pain care as recommended in the CDC guideline. Higher clinician reimbursement by insurance agencies and payers and improved clinician training on a full range of available pain treatments, followed by patient reassessment through multimodal care such as telemedicine could be more successfully implemented. The panel also endorsed the CDC’s call for greater distribution and utilization of naloxone as an alternative treatment.
The panel recommended that federal, state, and payer policies be revised to (1) avoid treating opioid dose as the primary benchmark for quality of care, shifting focus to maintaining pain control through alternative therapies;(2) better promote patient education regarding dose tapering, harms vs benefits, and access to care; and (3) formally track patient-level outcomes of interventions intended to reduce prescription rates.
Kroenke K, Alford DP, et al. Challenges with implementing the centers for disease control and prevention opioid guideline: A consensus panel report [published online January 25, 2019]. Pain Medicine. doi:10.1093/pm/pny307
This article originally appeared on Clinical Pain Advisor