Don’t tie the hands of clinicians

Prescription drug abuse and overdose is a tragic public health crisis, as is inadequately treated chronic pain. In addressing these two intertwined crises, we must avoid ameliorating one problem while worsening the other. Unfortunately, CDC’s proposed opioid prescribing guideline may not reach that goal.

Clearly, prescribers need guidance on safe and effective opioid use. Our research has found about four dozen professional society guidelines, and now CDC wants to add to the stack. CDC is compounding a problem common to those guidelines: using poor-quality evidence to recommend how to prescribe opioids without adequately involving people who treat pain every day.

Chief among our concerns are two recommendations: a three-day supply limit for opioid prescriptions used to treat acute pain, and a dose limit for opioids used to treat chronic pain. Other guidelines we’ve reviewed do not set limits on supplies or doses of opioids, because evidence is lacking and treating pain is too complex for such simple hardand-fast rules. While reason- able prescribing practices are vital, these limits tie the hands of clinicians whose patients will suffer because they need more medication to treat their pain, and won’t be able to substitute alternative treatments.

We heartily support the guideline’s recommendation to maximize the benefits of nonmedication treatments. These should always be part of a good pain care plan. They can reduce the need for opioids. But access is a challenge. Insurance coverage for treatments — such as physical therapy, counseling and chiropractic care — often is limited, while coverage for acupuncture, massage, biofeedback and yoga, all accepted by the Departments of Defense and Veterans Affairs as effective, can be hard to obtain. It is unethical to recommend use of treatments before ensuring their accessibility.

Working together, patient advocacy groups and pain and addiction specialists can craft a reasonable guideline that addresses all patients’ suffering — if CDC provides the opportunity.

Bob Twillman is executive director of the American Academy of Pain Management, which receives a small part of its income from opioid manufacturers.