Center for Disease Control Opioid Guidelines: notes from #IPPS2018

By: Kim Buonomo, PT, DPT, PHRC Lexington

At the International Pelvic Pain Society’s annual meeting I had the great opportunity to listen to two presenters discuss the role of medications in managing pelvic pain. In this blog, I’ll be talking about Dr. Stephen Ziegler PhD, JD from Purdue University’s lecture regarding the opioid epidemic and ways that we can improve medical management of patients with chronic pain who use opioids. He asked some really important questions, like “how do we define a successful outcome with opioid management?” And “how can we make our treatment better?” He presented an interesting perspective that opioids themselves can be effective at treatment of pain and are not “the enemy,” but providers do need to be very conscious of making sure they are only prescribing when appropriate. From his slides, “Clinicians should consider the circumstances and unique needs of each patient when providing care.”

There was a core group of experts that came together in late 2015 to develop the latest guidelines (he was very clear that these were not laws or mandated restrictions) that the Center for Disease Control has adopted as their recommended guidelines for opioid prescription. The way these providers met was not as transparent as medicine should be, and therefore damaged the credibility of the recommendations. Dr. Ziegler reported that there were secret meetings, anonymous experts with “weak” evidence and a very limited window for input from the greater community of physicians when compiling these guidelines. But, in March 2016, they released the guidelines we currently follow. The 12 recommendations are:

1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain

2. Before starting, establish treatment goals and consider how it will be discontinued if risks outweigh benefits.

3. Before and during opioid therapy, should discuss known risks of opioid treatment with the patient, knowing that alternative treatments including NSAIDs carry their own risks.

4. Should prescribe immediate release instead of long acting or extended release opioids.

5. When opioids are started, clinicians should prescribe lowest effective dosage. Use caution with opioid prescription at any dosage, but carefully re-assess individual benefits and risks when considering increasing the dosage beyond 50 morphine milligram equivalents (MME). Strongly recommended to avoid doses above 90 MMEs.

6. When prescribing for acute pain, use the lowest effective dose. Three days or less is often sufficient, greater than seven days is rarely needed.

7. Evaluate benefits and harms of continued therapy. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to lower and taper opioids when possible. (In short, if it’s not working, don’t do it.)

8. Clinicians should incorporate strategies to mitigate risk, including considering naloxone when factors that increase risk of opioid overdose, such as history of overdose, substance use disorder, higher opioid dosages, and concurrent benzodiazepine use, are present.

9. Use your state Prescription Drug Monitoring Program.

10. Use urine drug testing before starting and consider at least once annually.

11. Avoid co-prescribing opioids and benzodiazepines.

12. Offer evidence-based treatment for patients with opioid use disorder. (There was strong evidence for this one!)

Since these guidelines were not developed in a transparent way that welcomed input and feedback from the larger community of prescribing providers, Dr. Ziegler argues that even though the guidelines are okay, we cannot reliably use them, as they were not well-informed, they violated Institute of Medicine standards, and are susceptible to misrepresentation. They have also not been revised on a regular basis.

Dr. Ziegler reported that one of the issues with these guidelines is that many states took the recommendation to keep doses below 50 MMEs as a mandate. Suddenly prescriptions were dropped below 50 MME, which was not based on individual risk and resulted in involuntary tapering. He outlines the difference between individualized care and standardization of setting a number. This involuntary tapering dictates an upper limit of treatment dosage.

Involuntary tapering can have many negative effects. Two authors from the CDC released an article describing how this process can be associated with “withdrawal symptoms, damage the clinician-patient relationship and patients obtaining opioids from other sources.” The CDC released a statement that the conclusions in this article do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thankfully, Dr. Ziegler outlines hope for the future. We are getting media recognition for the opioid epidemic, which is promoting awareness of the problems we now face. His closing point was that the opioid crisis is a symptom of a bigger problem, and we need alternatives that are safe, effective, and covered by reimbursement (AKA cost-effective) in order to treat the true problem. He describes that we need appropriate and effective policies to reduce misuse but maintain balance to ensure appropriate access to medication. Thank you for a great and informative talk! It was fascinating to hear about this issue from an interdisciplinary standpoint.

Stay tuned for my next article reviewing Dr. Jay Joshi’s talk about the non-opioid advances in chronic pain!

FAQ

What are pelvic floor muscles?

The pelvic floor muscles are a group of muscles that run from the coccyx to the pubic bone. They are part of the core, helping to support our entire body as well as providing support for the bowel, bladder and uterus. These muscles help us maintain bowel and bladder control and are involved in sexual pleasure and orgasm. The technical name of the pelvic floor muscles is the Levator Ani muscle group. The pudendal nerve, the levator ani nerve, and branches from the S2 – S4 nerve roots innervate the pelvic floor muscles. They are under voluntary and autonomic control, which is a unique feature only they possess compared to other muscle groups.

What is pelvic floor physical therapy?

Pelvic floor physical therapy is a specialized area of physical therapy. Currently, physical therapists need advanced post-graduate education to be able to help people with pelvic floor dysfunction because pelvic floor disorders are not yet being taught in standard physical therapy curricula. The Pelvic Health and Rehabilitation Center provides extensive training for our staff because we recognize the limitations of physical therapy education in this unique area.

What happens at pelvic floor therapy?

During an evaluation for pelvic floor dysfunction the physical therapist will take a detailed history. Following the history the physical therapist will leave the room to allow the patient to change and drape themselves. The physical therapist will return to the room and using gloved hands will perform an external and internal manual assessment of the pelvic floor and girdle muscles. The physical therapist will once again leave the room and allow the patient to dress. Following the manual examination there may also be an examination of strength, motor control, and overall biomechanics and neuromuscular control. The physical therapist will then communicate the findings to the patient and together with their patient they establish an assessment, short term and long term goals and a treatment plan. Typically people with pelvic floor dysfunction are seen one time per week for one hour for varying amounts of time based on the severity and chronicity of the disease. A home exercise program will be established and the physical therapist will help coordinate other providers on the treatment team. Typically patients are seen for 3 months to a year.

What is pudendal neuralgia and how is it treated?

Pudendal Neuralgia is a clinical diagnosis that means pain in the sensory distribution of the pudendal nerve. The pudendal nerve is a mixed nerve that exits the S2 – S4 sacral nerve roots, we have a right and left pudendal nerve and each side has three main trunks: the dorsal branch, the perineal branch, and the inferior rectal branch. The branches supply sensation to the clitoris/penis, labia/scrotum, perineum, anus, the distal ⅓ of the urethra and rectum, and the vulva and vestibule. The nerve branches also control the pelvic floor muscles. The pudendal nerve follows a tortuous path through the pelvic floor and girdle, leaving it vulnerable to compression and tension injuries at various points along its path.

Pudendal Neuralgia occurs when the nerve is unable to slide, glide and move normally and as a result, people experience pain in some or all of the above-mentioned areas. Pelvic floor physical therapy plays a crucial role in identifying the mechanical impairments that are affecting the nerve. The physical therapy treatment plan is designed to restore normal neural function. Patients with pudendal neuralgia require pelvic floor physical therapy and may also benefit from medical management that includes pharmaceuticals and procedures such as pudendal nerve blocks or botox injections.

What is interstitial cystitis and how is it treated?

Interstitial Cystitis is a clinical diagnosis characterized by irritative bladder symptoms such as urinary urgency, frequency, and hesitancy in the absence of infection. Research has shown the majority of patients who meet the clinical definition have pelvic floor dysfunction and myalgia. Therefore, the American Urologic Association recommends pelvic floor physical therapy as first-line treatment for Interstitial Cystitis. Patients will benefit from pelvic floor physical therapy and may also benefit from pharmacologic management or medical procedures such as bladder instillations.

Who is the Pelvic Health and Rehabilitation Team?

The Pelvic Health and Rehabilitation Center was founded by Elizabeth Akincilar and Stephanie Prendergast in 2006, they have been treating people with pelvic floor disorders since 2001. They were trained and mentored by a medical doctor and quickly became experts in treating pelvic floor disorders. They began creating courses and sharing their knowledge around the world. They expanded to 11 locations in the United States and developed a residency style training program for their employees with ongoing weekly mentoring. The physical therapists who work at PHRC have undergone more training than the majority of pelvic floor physical therapists and as a result offer efficient and high quality care.

How many years of experience do we have?

Stephanie and Liz have 24 years of experience and help each and every team member become an expert in the field through their training and mentoring program.

Why PHRC versus anyone else?

PHRC is unique because of the specific focus on pelvic floor disorders and the leadership at our company. We are constantly lecturing, teaching, and staying ahead of the curve with our connections to medical experts and emerging experts. As a result, we are able to efficiently and effectively help our patients restore their pelvic health.

Do we treat men for pelvic floor therapy?

The Pelvic Health and Rehabilitation Center is unique in that the Cofounders have always treated people of all genders and therefore have trained the team members and staff the same way. Many pelvic floor physical therapists focus solely on people with vulvas, this is not the case here.

Do I need pelvic floor therapy forever?

The majority of people with pelvic floor dysfunction will undergo pelvic floor physical therapy for a set amount of time based on their goals. Every 6 -8 weeks goals will be re-established based on the physical improvements and remaining physical impairments. Most patients will achieve their goals in 3 – 6 months. If there are complicating medical or untreated comorbidities some patients will be in therapy longer.