Opioid prescribing: Physicians are misapplying the guidelines, CDC says

Physicians may be over-correcting their prescribing practices as a result of the opioid addiction crisis by cutting off patients that still need the drugs, according to the authors of the 2016 guidelines.

In a commentary published in April in the New England Journal of Medicine, Deborah Dowell, MD, MPH, Tamara Haegerich, Ph.D., and Roger Chou, MD, wrote that the guidelines are intended for primary care physicians treating chronic pain in adults, but that physicians have been misapplying the guidelines by limiting or cutting off opioid prescriptions for patients who need them.

“Efforts to implement prescribing recommendations to reduce opioid-related harms are laudable,” they wrote. “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.”

A physician over-correction on opioid prescribing is not surprising, given the scale of the problem. More than 130 people die daily in the United States from opioid overdose, and more than 11.4 million people have misused prescription opioids, according to U.S. government data.

In an effort to inform healthcare providers on the correct use of the guidelines, the CDC says the following practices are putting some patients at risk:

• Misapplication of the guidelines. The 2016 guideline is intended for primary care physicians treating chronic pain for patients 18 and older, and has been misapplied by cutting off medication to patients in active cancer treatment, patients experiencing acute sickle cell crises, or patients experiencing post-surgical pain.

• Hard limits or “cutting off” opioids. According to the guidelines, “When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should… avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.” The recommendation statement does not suggest discontinuation of opioids already prescribed at higher dosages.

• Abrupt tapering or sudden discontinuation of opioids.  This can result in severe withdrawal symptoms-including pain and psychological distress. This can lead some patients to seek other sources of opioids, including illegal street drugs.

• Medication-assisted treatment for opioid use disorder. The guidelines do not apply to the use of medication-assisted treatment for opioid use disorder.

Primary care physicians treating chronic pain in adults should apply the guidelines by working with patients receiving long-term opioid treatment at high dosages by reviewing the risks with patients in an empathetic way, collaborate with patients who agree to taper their dose and taper slowly enough to minimize withdrawal symptoms.

Physicians should also maximize the use of clinically recommended non-opioid treatments for pain and closely monitor overdose risk for patients who continue to take high doses of opioids.

According to Dowell, Haegerich and Chou’s article, the CDC is evaluating the consequences of the guidelines, and the Agency of Healthcare Research and Quality is conducting a “systematic review” on the effectiveness of various pain treatments. The guidelines will be updated in the future to include the latest research.

“Until then, we encourage implementation of recommendations consistent with the guideline’s intent,” the authors write.