The CDC has issued revised pain management guidelines on the prescription of opioids for outpatients aged 18 years or greater.
The updated guidelines are less stringent about specific titration caps and emphasize greater communication between patients and physicians to manage pain, as well as the exploration of complementary modalities.
Clinicians can familiarize themselves with one expert’s opinions to inform how they incorporate the new guidelines in clinical practice.
The revised guidelines include 12 recommendations intended to help clinicians determine whether to use opioids for pain management, choose specific drugs and dosages, set duration of administration with follow-up, and cover potential risks and harms.
According to an expert, the new guidelines represent a step toward safer, patient-centered pain management.
Clinical implications of revisions
To determine the clinical implications for these changes—which include a discontinuation of the titration cap of 90 MME—MDLinx spoke to Michael Sabia, MD, division head of pain management and associate professor of anesthesiology at Cooper University Health Care.
MDLinx: What were some of the unintended consequences of the 2016 guidelines?
Dr. Sabia: There was always a subtle fear when we prescribed controlled substances, asking ourselves, “What [are] we doing? [Are] we creating more of an epidemic with addiction and dependence?”
The guidelines came out in 2016 and the CDC said, “Try to stick to a certain amount of opioid, specifically 90 MME. If people are on 100 or 200 mg of morphine, try to cut it down so not a lot of patients are on a whole lot of these pain medications.”
So many practices—including some within Cooper—tried to say, “Mr. Jones, you’re on 200 mg, I’ve got to cut you in half today.” And those patients said, “But I had five back surgeries. I had part of my arm amputated. I walk with a walker.”
"Not everyone fits in that box."
— Michael Sabia, MD
“Cut down” was a good point to make, but I think too many people were stringent with that and [were] saying, “I have to make everyone cut down or I’m going to get audited. I’m going to get written to the state medical board. I’m going to have my license not reviewed.”
I think people suffered with more pain, some through withdrawal. Some patients got kicked out of their pain practice because doctors said, “I can’t prescribe this much. Look at these guidelines. You’ve got to go somewhere else.”
MDLinx: How do the new guidelines address these problems?
Dr. Sabia: First and foremost, the CDC made a point of the importance of communication with the patient, saying, “Let’s have a discussion. Let me explain to you what we’re going to [do] if we’re going to start opioid therapy”—[to] discuss with patients how the medicine works.
If something isn’t providing analgesia, let the doctor know and they can see if you need a new test to determine why it isn’t working—reevaluating these patients when they’re not responding.
The new guidelines also focus on the words multimodal and multidisciplinary, adding things like chiropractic, physical therapy, behavioral therapy, acupuncture, interventional pain management. Use these different disciplines and modalities to help instead of one drug.
Are the guidelines really ‘voluntary’?
MDLinx: Like the old guidelines, the CDC said that the revised guidelines are voluntary. But are they actually voluntary if a government agency is issuing them?
"When the CDC comes out with a statement, a guideline, or a paper, most if not all physicians take it seriously."
— Michael Sabia, MD
Dr. Sabia: We respect it, and we follow it closely.
MDLinx: How do you balance the voluntary nature of the guidelines with the need for individualized pain management, knowing that there may be an outlier patient who needs more than 90 MME, for example?
Dr. Sabia: I think it’s not losing perspective of what exactly is going on with the patient in front of you. Did they start with muscle pain a few months ago that progressively got worse? Did they not have a full workup and you’re titrating up the medicine? That’s not the way.
Whereas a patient who’s been with you maybe for a couple of years has seen multiple specialists and has had every test, has been very compliant coming to every office visit and doing all the treatments that you’ve recommended.
You’ve emptied your toolbox of adjuvant pain drugs, other medicines that are non-opioids, myofascial release, physical therapy, interventional treatments, and they respond well to the opioids.
"Over time, with the nature of these drugs, we all get tolerant to them."
— Michael Sabia, MD
If they’ve displayed tolerance and they’re compliant, and you’re clear on the pathology of what’s going on in their system, and they’re on more than what the previous guideline of 90 MME [capped], those are the patients who could be a little bit of an outlier.
Adhering to guidelines
MDLinx: How would you counsel a colleague who is not a pain management specialist or resident on adhering to these guidelines?
Dr. Sabia: Try to review with the patient all of the things that they’ve tried before going down the opioid route.
"Most patients will try to dismiss you: ‘The pain is so bad, doc. I’ve tried it all. Trust me. I’ve tried it all.’"
— Michael Sabia, MD
And when you really take the time, whether you’re in the ER or in a primary care office, you say, “Did you try these other nerve medicines? Lyrica, gabapentin, topamax?”
They may have tried one, but not all of them. Before you say, “The pain is so severe, I have to give an opioid,” you really want to exhaust all the non-opioid measures, and some of the interventions as well.
What this means for you
The updated CDC opioid prescribing guidelines put patient-physician communication at the center of care while underscoring the importance of incorporating other pain-management modalities. Avoiding an explicit titration cap may help physicians navigate pain management for patients who require higher opioid doses.