The Centers for Disease Control and Prevention (CDC) has reported that prescription opioid sales in the United States have increased by 300% since 1999, but there has not been an overall change in the amount of pain Americans report. Additionally, the rate of opioid overdoses has tripled since 2000, with 28,647 opioid-related deaths in 2014. The CDC has also found that existing opioid prescribing guidelines vary in recommendations, and that primary care providers say they receive insufficient training in prescribing opioid pain relievers. For these reasons, the CDC is developing their own guidelines for prescribing opioids to treat chronic pain.
Establishment of these guidelines makes a strong national statement regarding opioid use. When implemented, they stand to provide all practitioners with a roadmap to help them understand how to best initiate pain treatment and how to re-evaluate existing pain treatment for the safety of their patients. We are supportive of the proposed guidelines. In particular, we support the recommendations regarding first-line medication usage, as well as alternative therapies for the treatment of pain, including non-pharmacologic therapies such as physical therapy. Additionally, we agree with the proposed recommendations discussing the use of non-opioid pharmacologic therapies, such as Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) and select antidepressants and anticonvulsants, as appropriate. We also support the recommendations regarding patient education, including the use of opioid plans, medication agreements, and/or treatment contracts. Further, we agree with the recommendation advocating for initial use of short-acting opioids prior to long-acting opioids.
As part of the process, the guidelines were made available for comment and recommendations. Following are recommendations for the guidelines that we shared with the CDC.
Consider Existing State-Based Workers’ Compensation Guidelines
While we believe the intent of the CDC guidelines is to cover the many aspects of healthcare in this country, we recommend that a statement be included in the proposed guidelines acknowledging the existing pain, injury, and opioid treatment guidelines often required by state workers’ compensation laws when treating a work-related injury, and further qualifying that federal guidelines do not supersede any formally-adopted state guidelines. Doing so will ensure these proposed guidelines act in concert with existing state workers’ compensation laws and rules, and do not conflict or otherwise interfere with well-established workers’ compensation treatment parameters. This simple clarification will provide guidance for occupational health providers and avoid confusion between the proposed CDC guidelines and guidelines specifically developed for treating injured workers.
Clarify Morphine Equivalent Dose
We support establishment of a Maximum Morphine Equivalent (MME) per day level for prescribing opioids, but are concerned that the recommendation for two separate levels, >50 MME per day and >90 MME per day, may cause confusion when utilizing the guidelines. We therefore advocate for an evidence-based singular MME level, inclusion of language providing greater specificity surrounding the two recommended levels, or a range approach. Doing so will add more veracity to the recommendation and may eliminate confusion in the provider community as to when a specific MME level should be prescribed.
Provide Additional Guidance on When to Perform Follow-Up Evaluations
We also suggested additional guidance surrounding timeframes for evaluation of treatment therapies, particularly when using long-acting opioids. The guidelines recommend follow-up evaluations every three months. We believe that more frequent evaluations could provide opportunities for prescriber/patient education, general discussions with the patient regarding treatment, and opportunities for earlier detection of potential abuse or diversion behavior.
Add PBMs to the List of Entities with Access to PDMP Data
While we support the proposed recommendations regarding the use of Prescription Drug Monitoring Programs (PDMPs), we suggest care be taken to harmonize the various state requirements and federal guidelines. This is another area of potentially conflicting regulations, some specific to workers’ compensation, that needs to be balanced. We also recommend that Pharmacy Benefit Managers (PBMs) be added to the list of entities that can access PDMP data. As partners in managing pharmacy care for individuals, PBMs are uniquely situated to aid stakeholders in the detection of possible medication overuse, misuse, abuse, or other adherence concerns.
When to Test
Another recommendation we support is the initiation of urine drug testing before starting opioid therapy. It is our experience that initial testing to establish a “base-line” assists the prescriber in better understanding what medications the patient may be taking to treat conditions other than those related to the workers’ compensation injury or illness, as well as to identify the potential use of any illegal or illicit drugs. However, we are concerned that the proposed recommendation for “at least annual” testing may not advocate for sufficient frequency of testing to identify potential clinical concerns, and may lead to ineffective treatment, missed opportunities for treatment modification, or unintended consequences as a result of the current medication regimen. We also recommend that testing be random, unannounced, and included as part of any written treatment plan or medication agreement. Further, the treatment plan should indicate that adverse results could violate terms of the treatment plan, permitting the prescriber to take any steps they feel necessary, up to and including more frequent testing, tapering of therapy, or discontinuation of opioid prescribing.
A Show of Support
We appreciate and support the efforts of the CDC in bringing forward these guidelines, as well as the opportunity to lend a voice to the process by sharing comments. The CDC guidelines are an important initial step in bringing better care and sensible opioid care to patients across the country.