Correct. The very first line says, "This guideline provides recommendations for
primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 | MMWR
After reading these when they first came out, my initial assumption was that they intentionally left open the door for "Pain physicians" to prescribe more in limited cases. Another assumption was that they were leaving the door open for "slightly higher" doses in "limited numbers of cases." Seems logical that if they were okay with PCPs going up to 90 MME/day, that they'd like be okay with Pain Mrs going to 120 MME/day or so. But these are all
assumptions. None of it's spelled out, one way or the other. They haven't release any separate or specific "guidelines" for Pain physicians, to my knowledge. I think they're line of thinking is that by shear volume, the vast majority of opiate prescriptions are prescribe by PCPs. This is simply due to there being a much greater number of PCPs. They're likely thinking being that if they can reign in the largest segment first, then reassess and address the smaller subset of Pain specialists after that, while leaving the door cracked open a little bit, for some more aggressive treatment by specialists, preferably board certified specialists, in Pain. This is how I initially interpreted these guidelines.
As time has gone on, and as the regulators have turned up the heat on all of this, I've taken an even more conservative approach. The though process goes something like this:
If the regulators don't think its recommended or safe for PCPs to prescribe these drugs at these doses, it stands to reason that it's not safe for anyone to do it, since it's the property of the drugs themselves that create the danger. In other words, if a bad outcome occurred, I don't think it would be a great stretch at all, for the DEA, a licensing board to point to the regulations and say, "The guidelines have been out there. What makes you think you should ignore them? If they make sense for PCPs they make sense for all prescribers" and hold us accountable to them, when it serves their purposes. So, I concluded that there's essentially no risk in following them and some risk (maybe a lot, maybe not) to deviating from them slightly, based on the fact that I'm a specialist in Pain with all the certifications, etc.
So, about 3 months ago I notified all my patients that I'd no longer be prescribing over 90 MME/day, citing the CDC recs, opiate crisis, changing medical standards, etc. I gave them all 30 days to think about it and consider getting a second opinion and switching Pain MD if they disagreed, and let them know that after that we'd start a slow taper. The vast majority of my patients were already at or below 90 MME/day, quite at 0 MME/day. I had a few (maybe 10-12 between 90-120 MME/day) and only 1 or 2 over 120 MME/day that were rocks solid, stable, that I inherited, that had perfect UDS/PMP/no-aberrancy track records. As of today, I've got them all at 90 MME/day except one who I just took down to 120, who was my highest dose patient, and who I'll finish tapering down to 90 in the next 4-8 weeks. As you'd expect, the most difficult have been the ones who were on the highest doses. A couple vowed to change pain docs to find a "high dose opiate specialist" and they all eventually came back because they couldn't find anyone to go over 90 MME/day anyways. So far I'm glad I've done it and it's gone better than expected. It also feels better to think and say, "I don't prescribe high dose opiates. If you need them, you need to find someone who offers that service."
The more difficult task, has been applying the benzo + opiate arm of the guidelines. 1) I don't prescribe any therapeutic benzos (only 1-2 tabs, no refills, for occasional MRI or major procedure). 2) I realized i had more patients that I had thought, on opiates, that either PCPs or psych had on benzos. A few months after I started and nearly completed the opiate tapers down to 90 MME/day, I informed all my patients I'd no longer be prescribing opiates to anyone on chronic daily benzos. Since all of these patients have someone else prescribing the benzos, I expect it to take longer. But again, I told them they had 30 days to discuss with their PCP non-benzo alternatives to sleep, anxiety, etc, and
then they'll have to be actively tapering off them and that they were encouraged to get second opinion and even change MDs if they disagreed or thought they 'needed' it. This is easy to follow and enforce with the PMP. A few have surprise me and come back a month later and said, "I stopped my xanax already and I'm glad I did." The majority I'm following between now and the end of the year to make sure they're tapering. Most seem to be. Come Nov 1 or so, anyone not showing a meaningful benzo taper, I'll start slowly tapering off the opiates. Nearly every patient has said they feel they need their opiates more that their benzos. Similar to the opiate arm, most of it has gone better than expected, with a few exceptions of patients getting very distressed over it, but reluctantly complying. Again, the reason I'm giving, is the CDC guidelines, opiate epidemic, changing medical standards of care, and bluntly that the combination puts them at risk of accidental overdose and death. Most have replied with, "Well, I've been on this combination for 10 years. If it was so bad I thing it would have hurt me already." Although there may be an element of truth to that, I haven't let it persuade me to change my stance. Again, what's shocked me the most, is that I seem to have lost very few patients over it. What's helping, is that most of the PCPs prescribing the benzos are in my office (multi-specialty group) and they're very much on board with the change (except for one old guy who only works 1.5 days per week).
I'm glad I've done all this and in a weird way, I think a lot of the patients are too. I've had more than a few comment, "Yeah. I've been on these (benzos) forever. I know I need to come off them. It's just that no one ever brought it up."
So very soon, I'll have no-one on high dose opiates (over 90 MME/day) and no-one simultaneously on chronic daily opiates prescribed by other MDs (or myself, which I never did anyways). New patients will be told the same rules: No opiates over 90 MME/day (and no dose escalations, which I rarely if ever do anyways) and any concurrent benzos will need to be tapered starting immediately, that I consider it an absolute contraindication to chronic daily opiate treatment.
That being said, If there are a subset of Pain MDs out there that want to sub specialize in high and very-high dose opiates, that's there prerogative and the patients that feel they need that can go to them because I won't be doing it. And in an era where we have "injection only" docs that don't prescribe over zero MME/day, I think it's completely reasonable to have "low-moderate dose only" Pain MD. Without any convincing literature that high dose or very high dose improves outcomes, I don't think anyone has a very good argument as to why any of us need to be prescribing it. Yes, I realize you could say the same about low and moderate doses, and I'm sure that'll be the CDCs next target. We've go to leave for them something to do in 2018, after all.
