By: Kim Buonomo
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!