This is a hot topic in the news and among politicians in the state of Missouri. Many are aware of the Governor’s actions to move forward on a prescription drug monitoring program by executive order, even as the matter is debated in the House of Representatives and Senate. In March of 2018, letters were sent to the state’s Medicaid prescribers informing them of changes to the Missouri Opioid Prescription Intervention Program and calling on opioid prescribers to adhere to the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain. Doctors who are not adhering to the CDC guidelines could face professional sanction.
The CDC guidelines are controversial and were never meant to be a law by which physicians must adhere. Nor do they represent the standard of care. But to avoid potential issues with the State Board of Healing Arts and Medicaid program, it is important to know what the CDC recommends. Furthermore, the CDC Guidelines may be offered as support for the standard of care if a medical malpractice lawsuit is brought against a physician. The full text of the CDC guidelines can be found on the CDC website at www.cdc.gov.
The Guideline provides recommendations to primary care physicians who prescribe opioids for chronic pain and address 1)initiation and continuation of opioids; 2) selection, dosage, duration, follow up, and discontinuation; and 3) assessing risk and harms of opioid use.
The recommendations are as follows:
- Non-pharmacologic therapy and non-opioid pharmacologic therapy is preferred for chronic pain, unless the physician expects the benefits of opioids for pan and function outweigh the risks to the patient,
- Before starting opioid therapy, the physician should establish treatment goals, including realistic goals for pain and function. The physician should also consider how therapy will be discontinued if benefits do not outweigh the risks. Therapy should only continue if there is clinically meaningful improvement in the pain and function.
- Throughout the treatment, ongoing discussions of the risks and benefits of opioid therapy and the responsibilities of both the patient and physician for managing the therapy.
- When starting opioid therapy, prescribe immediate release opioids instead of extended release.
- When starting opioid therapy, prescribe the lowest effective dosage. If increasing the dosage to 50 morphine milligram equivalents or more per day, the physician should carefully assess the benefits and risks. The physician should avoid increasing the dosage to 90 morphine milligram equivalents or more per day, and if do so should carefully justify the decision to do so.
- When treating acute pain, prescribe the lowest effective dose of immediate release opioids and in no greater quantity than needed for the expected duration of the pain. 3 days or less is often sufficient, and more than 7 days is rarely needed.
- Evaluate the benefits and harms with the patient within 1-4 weeks of starting opioid therapy for chronic pain and dose escalation. Evaluations of benefit and harm should be done at least every 3 months or less for continued therapy. When the benefits do not outweigh the harms, optimize other therapies and work with patient to taper opioids to lower dosage or discontinue.
- Regularly evaluate patient for overdose and incorporate strategies to mitigate the risk of overdose. One such strategy could be to offer naloxone when factors that increase risk of overdose increase.
- Review history of controlled substance prescriptions using state prescription drug monitoring to determine if the patient is receiving opioid dosages or dangerous combinations that puts him or her at high risk of overdose. Physicians should review the database regularly during treatment ranging from every 3 months to every prescription.
- Regularly use drug urine test before starting and during treatment (at least annually) to assess prescription medications as well as other controlled substances and illicit drugs.
- Avoid prescribing opioids pain medication and benzodiazepines concurrently whenever possible.
- Offer or arrange for treatment for patients with opioid use disorder.
Consultation of the CDC Guidelines should be implemented in your practice to avoid any issues with the State of Missouri and potential claims of malpractice. Again these guidelines do not provide for the standard of care and are subject to change. A physician still must use their discretion and shared decision making between the physician and the patient to determine treatment, but should be aware of the CDC recommendations in dealing with opioid therapy.