April 25, 2019
“Effective implementation of the guideline requires recognition that there are no shortcuts to safer opioid prescribing or to appropriate and safe reduction or discontinuation of opioid use,” says Deborah Dowell, M.D. and Senior Medical Advisor for the Centers for Disease Control and Prevention in a recent article published in The New England Journal of Medicine.
This article was written in response to what Dowell refers to as the “misapplication” of the guidelines by physicians when it comes to opioid prescribing. However, the message here isn’t that the guidelines are wrong or ineffective, rather it’s getting back to Dowell’s point that “there are no shortcuts” when it comes to safe and effective prescribing of opioids.
The CDC Opioid Prescribing Guidelines Aim to Reduce Patient Harm, Not Patient Care
The issue begins with the 2016 publication of the CDC’s Guideline for Prescribing Opioids in response to the growing opioid epidemic that was spreading throughout the country. As a way to stem the tide and reduce the public risk for opioid addiction and overdose, many states adopted these guidelines or versions of them into their state laws as recommendations for physicians. The guidelines were well received, and Dowell herself notes that while opioid prescribing had been declining since 2012, there were “accelerated decreases” after the guideline’s release.
So why the recent clarification? In an effort to stamp out high-risk prescriptions, some physicians have gone far enough to potentially harm long-term pain medication patients. Dowell points out that the guideline states that “clinicians should… avoid increasing dosage ≥90 MME/ day,” and some have taken that to mean discontinuing opioids at that rate altogether. Situations like these are often not in the patient’s best interest, which is what the CDC’s clarification was all about.
Why Better Patient Monitoring Is Still Necessary
Dowell’s article boils down to the point that clinicians need to use these guidelines within a system, judging each case on its own merit: “implementing recommendations with individual patients takes time and effort.” Many patients who are going through cancer treatments or have other legitimate experience with prescription opioids are generally not the ones that have a high risk for abuse, and the CDC felt the need to reach out and remind us all of that.
What the 2016 guidelines have given many states is a framework for assessing new patient risk and having the tools to mitigate opioid abuse before it happens, something that Dowell notes is still a major focus: “Starting fewer patients on opioid treatment and not escalating to high dosages in the first place will reduce the numbers of patients prescribed high dosages in the long term.” In cases where the benefits of continuing prescriptions for a patient who is established on certain levels of opioids outweigh the risks, we should stay the course while also doing what we can to reduce the number of new opioids prescribed whenever possible. This strategy relies heavily on the discretion of the medical professionals treating the public. There needs to be a lot of interaction and monitoring to properly assess who is at risk and who needs these medications.
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