Wayne J. Riley, MD, MPH, MBA, MACP, president of the American College of Physicians (ACP) has sent a letter to the Centers for Disease Control and Prevention (CDC) reacting to its Draft Guideline for the Use of Opioids for Chronic Pain.
"The guideline development effort is both timely and necessary to help effectively address the increasingly clear public health problem of inappropriate opioid use and its related adverse consequences," Dr. Riley emphasized. ACP "particularly commends the CDC for focusing the Guideline on primary care healthcare professionals, who serve as the first contact for most patients suffering from pain-related conditions."
ACP divided its comments in the letter into those that are overarching and address the general Guideline document, and those specifically linked to a Guideline recommendation. The two overarching, general comments:
- State that the uniqueness of each patient's clinical situation and circumstances is a paramount consideration in the effective delivery of care. Thus, the full Guideline document should provide greater emphasis that it offers only "recommendations rather than prescriptive standards; providers should consider the circumstances and unique needs of each patient."
- Encourage the CDC to add a discussion within the Guideline document reflecting how these recommendations align with the other federal efforts (e.g. Office of National Drug Control Policy; initiatives of the National Institute on Drug Abuse and the Substance Abuse and Mental Health Administration; and the recently released initiative through the Department of Health and Human Services) to address the problems related to opioid medication use and misuse.
ACP provided a dozen specific recommendations, including:
- ACP policy supports the "consideration by physicians of the full array of treatments available for the effective treatment and management of pain."
- ACP suggests that the recommendation "Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function" be modified to recognize that there are some limited clinical circumstances under which reductions in pain without improvement in function might be an appropriate goal.
- ACP opposes arbitrary maximum dosages by payers and health plans. Actual dosages used should be based on the patient's clinical response.
- ACP supports the recommendation that, "Three or fewer days usually will be sufficient for most non-traumatic pain not related to major surgery," but suggests the sentence end, "with re-evaluation of the need for additional opioids at the conclusion of the three days."
- ACP supports this recommendation that highlights the importance of continued monitoring for benefits and harm of patients receiving opioid therapy.
- ACP recommends some increased elaboration on risk assessment approaches within the discussion section, and also an explicit statement in the discussion that primary care physicians consider referral to specialists in pain management for those patients whom they consider to be at high risk for opioid harm.
- ACP commends the CDC for including guidance related to how to properly and effectively use the information obtained from the prescription drug monitoring program (PDMP); ACP is particularly pleased to see the guidance that healthcare professionals "should not dismiss patients from their practice on the basis of PDMP information. Doing so can adversely affect patient safety, could represent patient abandonment, and could result in missed opportunities to provide potentially lifesaving information."
- ACP supports the recommendation that promotes the use of urine drug testing as part of a treatment plan for patients receiving opioid therapy for chronic pain, but encourages consideration of the limitations of this approach and its potential financial burden on the patient.
- ACP suggests the addition of an explicit statement in the discussion that primary care physicians consider referral to specialists in pain management for those patients currently on both benzodiazepines and opioids, or for the limited set of patients who might benefit from such co-prescribing.
- ACP believes that the primary care setting serves as the point of first healthcare contact for most individuals with opioid use disorder and suggests that the Guideline elaborate in greater detail approaches for these healthcare professionals to diagnose its presence. Improved ability by primary care professionals to diagnose this problem is a realistic goal.
Dr. Riley concluded the nine-page letter by encouraging CDC to engage in further appropriate questions and discussions with ACP.