The 2017 opioid prescribing guideline revisited: Implications for the United States and the Pain Society, as seen by the joint efforts of Jones and Beletsky

Unlike the 2016 version, those takeaways no longer include specific limits on the dose and duration of an opioid prescription that a patient can take, although deeper in the document it does warn against prescribing above a certain threshold. The new recommendations also explicitly caution physicians against rapidly tapering or discontinuing the prescriptions of patients who are already taking opioids — unless there are indications of a life-threatening issue.

Doctors and researchers say that the crisis of undiagnosed pain is hard to overstate. As patients with severe chronic pain saw their prescriptions reduced or cut off altogether, some of them had dire consequences like suicide or overdose, which is why they chose to turn to the nearby supply of illegal drugs.

The CDC’s leadership has taken a hit during the COVID-19 pandemic, and it will be crucial for them to coordinate and fix harms that came from the 2016 guidance. The agency has learned from the criticisms and harms of the last round. “So my hope is that CDC is now better equipped and prepared to take the guideline and translate it to the ground level,” he says.

The guideline recommendations are meant to guide shared decision-making between clinicians and patients, according to Christopher Jones, the acting head of theCDC’s National Center for Injury Prevention and Control.

The change in outlook is evident all over the new guidelines, says Dr. Samer Narouze, the president of the American Society of Regional Anesthesia and Pain Medicine.

While the voluntary guidelines are a welcome addition, their impact depends on how state and federal agencies respond to them, according to the health in justice action lab director.

For example, Beletsky points out that the definition of high-dosage opioid use in the 2016 recommendations was used to set legal limits. “The [2016] guideline itself was clear that this was not a bright line rule,” he says, “But it became a de facto label, separating appropriate and inappropriate prescribing,” he says. And this led law enforcement in some states to use the limit “as a sword to go after prescribers.”

These doses and limits – set without much scientific evidence to back them up – have had a chilling effect on doctors, says Cindy Steinberg, a patient advocate with U.S. Pain Foundation.

The director of the Pain Management Services says that they are very comprehensive and compassionate. The arbitrary marks of what’s acceptable and not acceptable was what got us into trouble with the 2016 guidelines, which made this blanket cut off for our patients.

The direction on reducing opioids when possible still raises some concerns for clinicians like Stefan Kertesz, a professor of medicine at the University of Alabama at Birmingham.

“I would emphasize that when you take a stable patient and reduce [their prescription], you’re engaged in an experiment,” says Kertesz. “Dose reduction is simply an uncertain intervention that sometimes helps and sometimes causes the patient to die. I would prefer they said that this is an uncertain intervention.

However, he adds that the strength of the new guidance is its repeated emphasis that a specific dose should not be used by agencies, law enforcement and payers to enforce a one-size fits all approach.

Source: https://www.npr.org/sections/health-shots/2022/11/03/1133908157/new-opioid-prescribing-guidelines-give-doctors-more-leeway-to-treat-pain

New Guidelines for the Prescription of Low-Dose Opioids: Implications for the Treatment of Addiction and Substance Abuse

She remembers one recent instance when an elderly patient of hers was suffering from severe arthritis in her neck and knees. “I recommended to the primary care doctor to start low-dose opioids and the primary care doctor said ‘no,’ ” Barreveld says. What happened? The patient was admitted to the hospital and spent eight days there. what did she get discharged on? Two to three pills of an opioid a day.”

The previous guidelines led to restrictions on prescribing being codified as policy or law. It’s not clear those rules will be re-written in light of the new guidelines even though they state they’re “not intended to be implemented as absolute limits for policy or practice.”

“That is a good idea, but it won’t work unless major agencies act immediately,” says Kertesz. “The DEA, the National Committee for Quality Assurance, and the Centers for Medicare and Medicaid Services, all three agencies use the dose thresholds from the 2016 guideline as the basis for payment quality metrics and legal investigation.”

The MAT Act would eliminate the special Drug Enforcement Administration waiver that doctors must apply for in order to prescribe buprenorphine (a medication that helps reduce the craving for opioids). It would enable community health aides to dispense this medication as long as it’s prescribed by a doctor through telemedicine. And it would give the Substance Abuse and Mental Health Services Administration responsibility to start a national campaign to educate health care practitioners about medications for opioid use disorder. The data shows that the medications are some of the most effective for preventing overdoses and helping people into recovery. But a 2019 report from the National Academies of Sciences, Engineering and Medicine found that less than 20 percent of people who could benefit have access to them.

There are several reasons for that, including stigma and a lack of understanding about how medications for opioid use disorder work. It’s a problem that doctors aren’t willing to treat addiction in the first place. Dropping the D.E.A. waiver will not be enough to alleviate that shortage; lawmakers will also have to find ways to ensure that addiction treatment enjoys the same robust reimbursement rates as other chronic conditions. But eliminating the waiver would still be a crucial step in the right direction. The prescription drugs that caused the epidemic shouldn’t be easier to get compared to the other medicines that could help.

Tonko’s MAT Act: A Mental Health Package for the Upper House of the New York State Assembly and the House of Representatives

The MAT Act, which was written by Representative Paul Tonko of New York, boasts some 248 co-sponsors and has already passed the House as part of a broader mental health package.