Policies that narrowly focus on restricting opioid analgesics stigmatize patients who need pain medication, creating a false perception that a single opioid prescription leads to inevitable dependence and death, said Bobby Mukkamala, MD, chair of the AMA Substance Use and Pain Care Task Force during an AMA Advocacy Insights webinar in which he was joined by three physician experts to address the nation’s drug-overdose epidemic.
A widely misapplied 2016 opioid-prescribing guideline from the Centers for Disease Control and Prevention (CDC) has been used against patients with pain to deny care, said Dr. Mukkamala, also chair of the AMA Board of Trustees.
The 2016 guideline includes specific limits on dosage and lengths of prescriptions, which most states, insurance companies and pharmacies turned into unbending regulations that substitute an arbitrary, one-size-fits-all threshold for the individualized treatment decisions of the physician.
The AMA detailed its concerns in a 17-page letter to the CDC (PDF) two years ago. Agency officials listened and the limits on dosage and duration have been removed from a draft of the revised guidelines that were submitted to the Federal Register for public comment. The CDC also notes that its guidelines should not be “a replacement for clinical judgment or individualized, person-centered care.”
The CDC’s new approach “provides a path to remove arbitrary prescribing thresholds, restore balance, and support comprehensive, compassionate care,” Dr. Mukkamala said in February. He added that the 2016 “guideline did nothing to stem the drug-overdose epidemic sweeping the country. In fact, the epidemic has become more lethal despite the CDC restrictive guideline due to illicitly manufactured fentanyl, fentanyl analogs, heroin, methamphetamine and cocaine.”
While noting that there’s still considerable work remaining to achieve CDC’s stated goal of supporting individualized patient care determinations, in a letter to the CDC in April (PDF), the AMA commended the agency for recognizing the harms done to patients and physicians by the misapplication of the guidelines and their “rigid numeric thresholds.”
Individual care plan is paramount
Another webinar panelist, Rita Agarwal, MD, addressed the limitations of one-size-fits-all opioid prescribing policies in pediatric pain management.
Some children will require more pain medications after surgery and some children won't require any at all. This distinction matters, said Dr. Agarwal, clinical professor of anesthesiology with Stanford University School of Medicine and past president of the Society for Pediatric Pain Medicine.
Physicians can do a better job of matching patients with their pain management needs, said Dr. Agarwal. While opioids are still a valuable tool, physicians may also consider multimodal approaches such as local or regional anesthesia, or topical local anesthetics wherever appropriate, she said.
Find out why access to treatment is key in addressing the drug-overdose epidemic.
Stigma in prescribing
In West Virginia, a qualitative study suggests a restrictive 2018 state opioid-prescribing law had the perverse effect of leading some patients use illicit drugs.
Webinar panelist Cara Sedney, MD, MA, is an associate professor of neurosurgery and residency program director at the West Virginia University Health Sciences Center. She and her study co-authors were concerned about the law’s impact on her patients.
To analyze the law’s effects on prescribing behavior, Dr. Sedney and colleagues looked at state prescription data and interviewed physicians, other prescribers, dispensers and patients—including those who used diverted or illicit substances.
Interviews with physicians revealed that many feared disciplinary actions resulting from opioid prescribing. This fear was present even before the law took effect, she noted.
“They gave examples of physicians in their own communities who were investigated … [and] had their practices ruined due to ongoing investigations even if they were never found to have done anything wrong,” Dr. Sedney said.
Unsurprisingly, some doctors said they wouldn’t prescribe anymore once the law took effect. “They wouldn't even prescribe gabapentin,” said Dr. Sedney. In interviews, some patients desperate for pain control said they transitioned to illicit substances.
The AMA believes that science, evidence, and compassion must continue to guide patient care and policy change as the nation’s opioid epidemic has become a more dangerous and complicated illicit drug overdose epidemic. Learn more at the AMA's End the Epidemic website.
