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Fowler Bell Blog – Worker's Comp

CDC issues guidelines for Opioids, it’s a start.

The CDC published their recommendations on opioids on March 15, 2016 in the Journal of the American Medical Association. Let’s look at the major points as they apply to Kentucky Workers’ Compensation patients.

In 1999 to 2014, more than 165,000 persons died of overdose related to opioid pain medication in the United States. In 2013 alone, an estimated 1.9 million persons abused or were dependent on prescription opioid pain medication.

These Guidelines are for primary care clinicians who are treating patients with chronic pain (painful conditions that typically last >3 months). The recommendations are voluntary and are based on emerging evidence.

Acute Pain

Acute pain can often be managed without opioids.

Prescribe the lowest effective does of immediate release opioids.

“Three days or less will often be sufficient; more than 7 days will rarely be needed.”

Postsurgical pain is outside the scope of this guideline but has been addressed elsewhere.

Chronic Pain

Nonopioid therapy is preferred for treatment of chronic pain. This includes: exercise; NSAIDs, acetaminophen, anticonvulsants, and SNRIs. Opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy.

Establish treatment goals with patients. Goals should include improvement in both pain relief and function. Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function

Avoid concurrent opioids and benzodiazepines whenever possible.

UDS before starting opioid therapy, and continue to do so at lease annually. If clinicians suspect their patient might be sharing or selling opioids and not taking them, clinicians should consider urine drug testing to assist in determining whether opioids can be discontinued without causing withdrawal. A negative drug test for prescribed opioids might indicate the patient is not taking prescribed opioids, although clinicians should consider other possible reasons for this test result. Clinicians should not dismiss patients from care based on a urine drug test result. This could have adverse consequences for patient safety, including missed opportunities to facilitate treatment for substance use disorder.

When starting long term opioid therapy the prescription should be immediate-release opioids not extended/long acting opioids (“ER/LA”). Clinicians should not initiate opioid treatment with ER/LA opioids and should not prescribe ER/LA opioids for intermittent use. In general, avoiding the use of immediate-release opioids in combination with ER/LA opioids is preferable. Because dosing effects of transdermal fentanyl are often misunderstood by both clinicians and patients, only clinicians who are familiar with the dosing and absorption properties of transdermal fentanyl and are prepared to educate their patients about its use should consider prescribing it.

Monitor Kasper “ranging from every prescription to every 3 months.” Clinicians should discuss safety concerns with other clinicians who are prescribing controlled substances for their patient. Clinicians should not dismiss patients from their practice on the basis of Kasper information. Doing so could result in missed opportunities to provide potentially lifesaving information and interventions.

Clinicians should avoid prescribing opioids to patients with moderate or severe sleep-disordered breathing whenever possible. Clinicians should use additional caution and increased monitoring for patients with anxiety or depression.

Morphine milligram equivalence (“MME”) should be the lowest effective does, if increased to over 50 MME one should carefully reassess evidence of individual benefits and risks. Practitioners should avoid increasing dosage to 90 MME “or carefully justify a decision to titrate dosage to 90 MME or more per day.” Established patients already prescribed high dosages of opioids (?90 MME), including patients transferring from other clinicians, should be offered the opportunity to reevaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan.

Tapering Plans

When opioids are reduced or discontinued, a taper slow enough to minimize symptoms and signs of opioid withdrawal should be used. A decrease of 10% of the original dose per week is a reasonable starting point; tapering plans may be individualized based on patient goals and concerns. Slower tapers (eg, 10% per month) might be appropriate and better tolerated, particularly when patients have been taking opioids for years. More rapid tapers might be needed for patients who have overdosed on their current dosage.

Primary care clinicians should collaborate with mental health clinicians and with other specialists as needed to optimize nonopioid pain management, as well as psychosocial support for anxiety related to the taper.

My Thoughts

We have been arguing many of these points for years, with growing success before doctors and judges. Our arguments have even more bite now with the CDC’s recommendations, which provide us with backing to try and stop the addiction process in the acute stage, and also to fight it in the chronic stage. I know that I’ll be questioning treating doctors and Plaintiff IME doctors about their opinions in light of the CDC’s recommendations.

You can find the guidelines, in whole, at http://jama.jamanetwork.com/article.aspx?articleid=2503508