Treating Pain Amidst Multiple Guidelines

The Challenges Physicians Face

Taking care of patients in chronic pain has always been a challenge for physicians. We face many different challenges trying to help people who suffer with pain, the first hurdle figuring out the cause. There’s a long list of things that can cause something as common as chronic low back pain. We have to perform the appropriate history and physical exam, order the right diagnostic studies and refer to specialists when necessary. Once we have established why the patient is in pain, we have to develop an appropriate treatment plan. This can, and usually should, involve multiple different treatment options, especially for chronic pain patients. In developing this plan, we also have to consider other medical comorbidities that a patient may have. With pain that has been present for any significant length of time, we also have to consider multiple psychological factors that can affect the patient’s experience with pain and treatment outcomes. As complicated as this is, chronic pain is anything but uncommon. With chronic daily pain affecting one third of all Americans, we all see chronic pain patients regardless of specialty or area of practice. On top of all of these issues, we now have the added challenge of dealing with multiple different guidelines surrounding opioids.

Opiods Aren’t the Only Option

Opioids are only one of many different treatment options for chronic pain patients. Unfortunately, they have moved too high on the treatment algorithm for most doctors over the last 20 years. As I’m sure anyone reading this article already knows, the rates of opioid prescribing have skyrocketed over the last 20 years both nationally as well as in Tennessee. Tennessee has always been near the top of the list for every negative statistic related to prescription opioids. This increase in prescription opioid utilization, along with the dramatic rise in illicit opioid availability, has created the opioid epidemic that our nation faces today. Many different factors have contributed to the increase in prescription opioid utilization by physicians. The pharmaceutical industry launched an aggressive marketing campaign that encouraged increased utilization by physicians based on weak data. Insurance companies have a long history of denying coverage for things like physical therapy, injections, and psychologically based treatments. We also have an aging and more obese population who often demand opioids as a quick and easy fix for their ailments.

Guidelines Introduced

In response to the abuse, addiction, and overdoses that followed these trends, multiple agencies and organizations introduced guidelines to limit opioid prescribing in order to curb this epidemic. These efforts started as early as 2002 when Tennessee started developing its Controlled Substance Monitoring Database (CSMD). The Prescription Safety Act of 2012 required all prescribers to register in the CSMD and to query it every time they wrote a prescription over 7 days. It also required the Department of Health to create guidelines on proper opioid prescribing which they released in 2014. The CDC also created guidelines for primary care physicians that were released in early 2016. Laws have been passed related to the regulation and oversight of pain clinics. These efforts were created with good intentions to improve medical care and save lives, and the guidelines were very effective at reducing the dose and number of opioid prescriptions nationally and statewide. We have seen a decrease in the number of prescriptions as well as the total dose of opioids across the country, but the declines have been especially noticeable in Tennessee. However, despite this drop, our numbers are still near the top of the list when compared to other states.

Most recently, we have seen the passage of Public Chapter 1039, effective July 1, 2018, which imposes very strict and absolute limits on opioids prescribed for acute and post-operative pain. Opioid prescriptions of three days or less and 180 total morphine milligram equivalent (MME) dosage or less do not require additional criteria to be met. All other opioids require certain criteria to be met by the prescriber and also must be dispensed from the pharmacy as a partial fill. This means that for a 10-day prescription, the pharmacist can only dispense 5 days’ worth at the initial visit, and the patient must return for the second half of the prescription if he/she still needs it. This effort was based on data that shows opioid exposure for longer than a 10-day duration dramatically increases the chance that a person will still be on opioids one year later. This measure will hopefully decrease addiction through prevention of initial exposure. While there are some notable exceptions to this law, for chronic pain, palliative care, and cancer pain, it represents a dramatic departure from traditional guidelines because it is a law that imposes strict limits on dose and duration of a medical treatment.

Other Entities Enact New Requirements

Commercial insurance companies, state and federal payors and pharmacy benefit managers have also enacted new requirements. Many of these policies require time-consuming prior authorization steps that overwhelm both small and large practices. Unfortunately, the policies are not uniform and this creates a difficult and confusing burden for physicians. These requirements have caused some physicians to stop treating pain with opioids completely. There may also be an adverse effect on chronic pain patients who will have to deal with debilitating pain without the one measure that has proven effective for them. One study [1]of 3108 pain patients indicates that 84 percent report more pain and a decreased quality of life as a result of the CDC guidelines, and 42 percent have considered suicide. We also have to take into account the unintended consequence of increased mortality from illicit opioids such as heroin and illicit fentanyl analogues. While we have seen dramatic decreases in opioid prescribing patterns, we have seen an increase in overdose deaths as people turn to street drugs.

As we navigate these difficult times, it is important that we always keep our patients’ best interest at the forefront of our decisions. While it is imperative that we change our mindset on when and how we prescribe opioids, we must also remember that there are patients out there that do suffer from chronic pain and deserve to be treated with the same compassion as anyone else.

[1] https://www.painnewsnetwork.org/stories/2017/3/13/survey-finds-cdc-opioid-guidelines-harming-patients