Docs Fall Short in Following Opioid Prescribing Guidance

Megan Brooks
April 25, 2019

Physicians do not consistently follow the 2016 Centers for Disease Control and Prevention (CDC) opioid prescribing guideline, potentially jeopardizing patient health and safety, experts say.

Although the medical community has largely embraced the advice for safer opioid prescribing to reduce opioid-related harms, some policies and practices purportedly derived from the guideline have been inconsistent with, and often go beyond, its recommendations, CDC guideline authors Deborah Dowell, MD, and colleagues note in a commentary published April 24 in the New England Journal of Medicine.

A consensus panel recently highlighted these inconsistencies in an article in the journal Pain Medicine. They include inflexible application of recommended opioid dosage and duration thresholds and policies that encourage hard limits and abrupt tapering of drug dosages, resulting in sudden opioid discontinuation or dismissal of patients from a physician's practice.

The guideline does not support abrupt tapering or sudden discontinuation of opioids.

"These practices can result in severe opioid withdrawal symptoms including pain and psychological distress, and some patients might seek other sources of opioids.

"In addition, policies that mandate hard limits conflict with the Guideline's emphasis on individualized assessment of the benefits and risks of opioids given the specific circumstances and unique needs of each patient," the CDC said in a statement.

No Shortcuts

The consensus panel also cited the potential for misapplication of the recommendations to populations outside the scope of the guideline, including patients with pain associated with cancer, surgery, and acute sickle cell crisis.

There have also been reports of misapplication of the guideline's dosage thresholds to opioid agonists for treatment of opioid use disorder.

"Such actions are likely to result in harm to patients," write Dowell and colleagues.

"Effective implementation of the guideline," they add, "requires recognition that there are no shortcuts to safer opioid prescribing (which includes assessment of benefits and risks, patient education, and risk mitigation) or to appropriate and safe reduction or discontinuation of opioid use.

"Starting fewer patients on opioid treatment and not escalating to high dosages in the first place will reduce the numbers of patients prescribed high dosages in the long term."

The CDC offers several tools to assist clinicians, including a pocket guide on tapering and a mobile app, as well as online training with motivational interviewing components and information about nonopioid treatments for pain.

The CDC is also working to identify ways to integrate recommendations into medical education and to support best practices among the next generation of medical professionals.

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SOURCE: Medscape, April 25, 2019. N Engl J Med. Published online April 24, 2019.

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