Gamechanger: AMA Letter to CDC Regarding 2016 Opioid Guidelines

Ducttape

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    not sure if it is a "good" game changer.

    what makes you think so, and in what ways?



    in some respects, this document allows PCPs and non-opioid trained individuals carte blanche to go back to prescribing whatever doses they want. yes, what was done with the original guidelines went way too far, particularly with respect to pharmaceutical and pharmacy regulations.

    getting to the specific changes to Recommendations:

    1. i don't like the wording in either document, that focuses more on opioids than non-opioid therapy. yes, it is in a document about opioid prescribing, but it is the first recommendation and the one most likely to "stick" in readers..

    we prescribers "should consider using opioid therapy only if expected benefits are anticipated to outweigh" puts the opioid therapy front and center, and lends one to think of opioid therapy sooner in the paradigm than, say "after all else fails, and the patient has severe pain with limited functioning and little possibility of improvement, then consider opioid therapy".

    2. for the most part, agree.

    3. clinicians should not be "encouraged" - they need to have that initial discussion.

    4. agree

    5. disagree on removal of hard cap with respect to PCPs. this will encourage PCPs to prescribe whatever they feel is indicated.

    would have suggested that PCPs alone should not go above the hard cap of 90, but then state that "this applies to prescribers who are not pain or palliative care specialists. PCPs may utilize the expertise of pain and palliative care certified specialists to make the determination that levels above 90 MME are appropriate for a particular patient".

    6. too broad. at one point in time, i got a series of referrals from an orthopedic practice. one of the ortho docs would routinely prescribe opioids after surgery. unfortunately, he would never stop. one patient would get a 1 month prescription after an arthroscopy - 20 years previously.

    7. i believe it is the DEA requirement that patients be assessed every 3 months. this recommendation suggests that the AMA is not aware of the legal aspects of opioid prescribing.

    8. this recommendation could be misconstrued by patients to insist that proper opioid addiction and misuse by itself is insufficient grounds to not prescribe opioids for chronic nonmalignant non-palliative pain.

    9. weakens PMP, and will allow patients the opportunity to state that the PMP does not matter in terms of the physician prescribing. these changes seem double edged to me.

    10. same thing. UDS not required and should not be used as a determinant on continuing prescribing. this will encourage aberrant behavior.

    11. don't like the wording, but concurrent use still shouldn't be encouraged.

    12.

    13. this one i really don't like, because all those addicts will be knocking on our doors saying "the CDC says it is okay to give me narcs".

    here it is:

    Recommendation 13

    Patients with a current or history of an opioid use disorder should receive effective pain care, including opioid therapy when clinically indicated and in consideration of known risks and benefits.
     
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    drusso

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    1. Attending Physician
      not sure if it is a game changer.

      what makes you think so, and in what ways?

      in some respects, this document allows PCPs and non-opioid trained individuals carte blanche to go back to prescribing whatever doses they want. yes, what was done with the original guidelines went way too far, particularly with respect to pharmaceutical and pharmacy regulations.

      getting to the various changes to recommendations:

      1.
      i don't like the wording in either document, that focuses more on opioids than non-opioid therapy. yes, it is in a document about opioid prescribing, but it is the first recommendation and the one most likely to "stick" in readers..

      we prescribers "should consider using opioid therapy only if expected benefits are anticipated to outweigh" puts the opioid therapy front and center, and lends one to think of opioid therapy sooner in the paradigm than, say "after all else fails, and the patient has severe pain with limited functioning and little possibility of improvement, then consider opioid therapy".

      2. for the most part, agree.

      3. clinicians should not be encouraged - they need to have that initial discussion.

      4. agree

      5. disagree on removal of hard cap with respect to PCPs. this will encourage PCPs to prescribe whatever they feel is indicated.

      would have suggested that PCPs alone should not go above the hard cap of 90, but then state that "this applies to prescribers who are not pain or palliative care specialists. PCPs may utilize the expertise of pain and palliative care certified specialists to make the determination that levels above 90 MME are appropriate for that particular patient".

      6. too broad. at one point in time, i got a series of referrals from an orthopedic practice. one of the ortho docs would routinely prescribe opioids after surgery. unfortunately, he would never stop. one patient would get a 1 month prescription after an arthroscopy - 20 years previously.

      7. i believe it is the DEA requirement that patients be assessed every 3 months. this recommendation suggests that the AMA is not aware of the legal aspects of opioid prescribing.

      8. this recommendation could be misconstrued by patients to insist that proper opioid addiction and misuse by itself is insufficient grounds to not prescribe opioids for chronic nonmalignant non-palliative pain.

      9. weakens PMP, and will allow patients the opportunity to state that the PMP does not matter in terms of the physician prescribing. these changes seem double edged to me.

      10. same thing. UDS not required and should not be used as a determinant on continuing prescribing. this will encourage aberrant behavior.

      11. don't like the wording, but concurrent use still shouldn't be encouraged.

      12.

      13. this one i really don't like, because all those addicts will be knocking on our doors saying "the CDC says it is okay to give me narcs".

      here it is:

      Recommendation 13

      Patients with a current or history of an opioid use disorder should receive effective pain care, including opioid therapy when clinically indicated and in consideration of known risks and benefits.

      It's a gamechanger because it calls for advocating for IPM which PROP intentionally left out of 2016. PROP's letter is so thin...it's almost as if they just don't understand pain management.

       
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        not sure if it is a game changer.

        what makes you think so, and in what ways?

        in some respects, this document allows PCPs and non-opioid trained individuals carte blanche to go back to prescribing whatever doses they want. yes, what was done with the original guidelines went way too far, particularly with respect to pharmaceutical and pharmacy regulations.

        getting to the various changes to recommendations:

        1.
        i don't like the wording in either document, that focuses more on opioids than non-opioid therapy. yes, it is in a document about opioid prescribing, but it is the first recommendation and the one most likely to "stick" in readers..

        we prescribers "should consider using opioid therapy only if expected benefits are anticipated to outweigh" puts the opioid therapy front and center, and lends one to think of opioid therapy sooner in the paradigm than, say "after all else fails, and the patient has severe pain with limited functioning and little possibility of improvement, then consider opioid therapy".

        2. for the most part, agree.

        3. clinicians should not be encouraged - they need to have that initial discussion.

        4. agree

        5. disagree on removal of hard cap with respect to PCPs. this will encourage PCPs to prescribe whatever they feel is indicated.

        would have suggested that PCPs alone should not go above the hard cap of 90, but then state that "this applies to prescribers who are not pain or palliative care specialists. PCPs may utilize the expertise of pain and palliative care certified specialists to make the determination that levels above 90 MME are appropriate for that particular patient".

        6. too broad. at one point in time, i got a series of referrals from an orthopedic practice. one of the ortho docs would routinely prescribe opioids after surgery. unfortunately, he would never stop. one patient would get a 1 month prescription after an arthroscopy - 20 years previously.

        7. i believe it is the DEA requirement that patients be assessed every 3 months. this recommendation suggests that the AMA is not aware of the legal aspects of opioid prescribing.

        8. this recommendation could be misconstrued by patients to insist that proper opioid addiction and misuse by itself is insufficient grounds to not prescribe opioids for chronic nonmalignant non-palliative pain.

        9. weakens PMP, and will allow patients the opportunity to state that the PMP does not matter in terms of the physician prescribing. these changes seem double edged to me.

        10. same thing. UDS not required and should not be used as a determinant on continuing prescribing. this will encourage aberrant behavior.

        11. don't like the wording, but concurrent use still shouldn't be encouraged.

        12.

        13. this one i really don't like, because all those addicts will be knocking on our doors saying "the CDC says it is okay to give me narcs".

        here it is:

        Recommendation 13

        Patients with a current or history of an opioid use disorder should receive effective pain care, including opioid therapy when clinically indicated and in consideration of known risks and benefits.

        i have an idea, let's sacrifice legitimate pain patients and condemn them to an existence worse than death for the sake of protecting addicts from themselves. that seems totally morally legitimate to me. we all have a duty to pitch in to help the most worthless members of society, even if at the expense of better people's health and lives.
         

        Laryngospasm

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        1. Attending Physician
          This is a contentious, litigious, dangerous issue. Nevermind that there is almost no data that longer term higher dose prescribing even benefits the patients. Choosing to make higher dose prescribing part of your practice should be done with extreme caution. At the end of the day there is no legal protection for the physician who is trying to help someone with debilitating pain even if that patient acknowledges they are at an increased risk of death and just wants relief. The house always wins... you at best win an rvu.
           
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            This is a contentious, litigious, dangerous issue. Nevermind that there is almost no data that longer term higher dose prescribing even benefits the patients. Choosing to make higher dose prescribing part of your practice should be done with extreme caution. At the end of the day there is no legal protection for the physician who is trying to help someone with debilitating pain even if that patient acknowledges they are at an increased risk of death and just wants relief. The house always wins... you at best win an rvu.

            In fact I think that this document is legal protection for physicians who encounter legal issues regarding opiates.

            I don't think anyone anymore embraces high dose opiates- that lesson was learned. However, there are many docs (myself included) who feel there is a place for lower dose opiates in certain patients.

            The CDC guidelines were taken verbatim by most physicians. Any deviation from those guidelines could result in legal issues for the physician involved. These suggestions show that this situation is more grey than black and white and recognizes that not all patients fall into a nice, neat category or plan of action.

            While I do not agree with some of the points the AMA made, I do think this was needed, as the CDC guidelines were too draconian.
             
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