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Opioid Patient Protection Recommendations accepted for publication in Mayo Clinic Proceedings

October 1, 2020, CHICAGO, Illinois – A multidisciplinary consensus panel convened by the American Academy of Pain Medicine Foundation has issued new recommendations in Mayo Clinic Proceedings about ensuring patient protections when tapering opioids. The recommendations offer guidance to pain specialists and primary care providers—as well as patients, payors, and regulators—about the intricacies of opioid reduction.

In recent years, prescribers in the United States have made considerable efforts to reduce or discontinue opioids in patients who have taken them long term. While opioid reduction efforts have had generally beneficial effects, there have been unintended consequences. Abrupt reduction or discontinuation has been associated with harms that include serious withdrawal symptoms, psychological distress, self-medicating with illicit substances, uncontrolled pain, and suicide. Key questions remain about when and how to safely reduce or discontinue opioids in different patient populations. The consensus panel recommendations include clear, evidence-informed steps providers can take to clarify the indications for tapering long-term opioids and how to ensure patient safety throughout each step of a taper.

“Clinicians face dilemmas when caring for patients taking opioids, as various guidelines, patient preferences, and clinical impressions of risks and benefits may be in conflict,” says AAPM Past President Edward Covington, MD, lead author of the AAPM Foundation project. “Our findings indicate that harm can result from abrupt tapers and emphasize the importance of balancing patient collaboration and desires with clinician responsibility to prescribe wisely.”

The consensus panel’s recommendations are the result of a rigorous and collaborative process, including consensus-building discussions, analysis, and interpretation of data. “We convened a consensus panel of experts in long-term opioid treatment, substance use disorders, and opioid reduction with the goal of providing useful criteria for dose continuation versus reduction along with strategies for the comfortable and humane tapering of opioids, when indicated,” Dr. Covington said.

Hear more from Dr. Covington by viewing this video interview he conducted with co-author Mark Sullivan, MD PhD.

Recommendations also address topics such as patient factors that increase risk with long-term opioid therapy, indications for tapering long-term opioids, common withdrawal symptoms, and buprenorphine initiation in patients on opioids for pain. Several of the panelists presented a Spotlight Session about this project at AAPM’s 2020 Annual Meeting. A recording of this session is available on demand in the AAPM Education Center at no cost for members and $25 for nonmembers.

About AAPM

The American Academy of Pain Medicine is the premier medical association for pain clinicians and their treatment teams with some 2,000 members. Now in its 36th year of service, the Academy’s mission is to advance and promote the full spectrum of multidisciplinary pain care, education, advocacy, and research to improve function and quality of life for people in pain. Information is available on the Academy’s website at painmed.org.

About AAPM Foundation
The AAPM Foundation was created in 2011 to support the American Academy of Pain Medicine’s (AAPM) efforts. The Foundation supports AAPM’s core purpose to optimize the health of patients in pain and eliminate the major health problem of pain by advancing the practice and the specialty of pain medicine. Information is available on the Foundation’s website at aapmfoundation.org.

How Should Medical Education Better Prepare Physicians for Opioid Prescribing?

Opioid overprescribing is a key contributor to the current crisis. Changing how ethics is taught in connection with opioid prescribing is one area for improvement. In US medical schools, current training in ethics and opioid prescribing is variable, incorporating a diverse range of concepts, teaching modes, assessment strategies, and faculty experience. This article recommends integrating clinical case-based teaching and longitudinal application, comprehensive assessment, and additional training in ethical deliberation about opioid prescribing to better prepare physicians to responsibly prescribe and manage opioid-based phases of patients’ pain care. Read the details.

What Does Good Pharmacist-Physician Pain Management Collaboration Look Like?

Physicians and pharmacists have critical roles in addressing the current opioid epidemic and ensuring appropriate care for patients with pain. Both physicians and pharmacists have responsibilities to ensure that opioids are prescribed and dispensed for legitimate medical purposes and to meet legal requirements. Health care systems have implemented policies to curb opioid prescribing and dispensing, but many of these policies place additional pressures on clinicians and can cause friction between physicians and pharmacists. Cases discussed in this article highlight 5 optimal physician and pharmacist behaviors that can help foster better collaboration between these clinicians, improve management strategies, and improve care of patients with pain. Read the details.

CDC Opioid Workgroup Appoints AAPM Members

AAPM members Beth Darnall, PhD, and Mark Wallace, MD, were appointed to the Centers for Disease Control Opioid Workgroup by the Board of Scientific Counselors of the Centers for Disease Control and Prevention’s National Center for Injury Prevention and Control (BSC/NCIPC). The Opioid Workgroup (roster), is responsible for reviewing the quality of evidence reviews and guidelines, and will make recommendations regarding revisions to existing CDC opioid prescribing guideline and the creation of new prescribing guidelines for acute and chronic pain.

Trends in Opioid Prescribing and Self-Reported Pain Among US Adults.

Abstract: Clinically informed efforts to curb inappropriate opioid prescribing seek to reduce prescribing to adults with lower pain levels that are potentially manageable with alternative therapies. According to the Medical Expenditure Panel Survey, the annual share of US adults who were prescribed opioids decreased from 12.9 percent in 2014 to 10.3 percent in 2016, and the decrease was concentrated among adults with shorter-term rather than longer-term prescriptions. 

AMA Responds to Walmart’s “Refusal to Fill” Policy

The American Medical Association (AMA) continues to express its concerns over Walmart’s corporate prescription opioid restriction policy in its recent letter to Walmart’s Chief Medical and Analytics Officer. The new policy limit opioid prescriptions to seven days or 50 morphine milligram equivalents (MME) has caused harm to patients with acute, palliative, cancer-related, chronic pain and other medical conditions requiring amounts or doses greater than the corporate policy. According to the AMA, “this policy has disrupted legitimate medical practices that receive form letters telling them their prescribing rights under state law will be superseded by a Walmart-created algorithm that deems a physician unfit to prescribe.”

AAPM has echoed AMA advocacy efforts on this subject. In 2018, AAPM Past President, Steven P. Stanos, DO, traveled to Walmart headquarters with an AMA-led contingency to discuss these issues including ensuring access to comprehensive pain care; opioid prescribing guidelines; pain care and stigma; and reducing opioid misuse and diversion. Later in the year, AAPM’s AMA Delegates joined other pain and palliative medicine societies to rally the AMA House of Delegates to adopt a policy opposing the misuse of the 2016 CDC Guideline.

Further, AAPM’s advocacy efforts around the misapplication of the CDC Guideline for Prescribing Opioids for Chronic Pain has been ongoing, and included the AAPM Foundation consensus panel report that addressed the challenges of implementing the CDC Guideline. In April, the CDC issued an advisory cautioning against the misapplication of its guideline, following the publication of an editorial in The New England Journal of Medicine. The editorial referenced the AAPM Foundation consensus panel report and recognized that some policies and practices derived from the CDC Guideline are inconsistent and go beyond its recommendations, causing undo difficulty for patients and their providers. Furthermore, the editorial acknowledges the need for improved patient access and provider reimbursement for multidisciplinary pain care.

AAPM continues to advocate for the pain medicine and its members, continuing to serve as the voice for pain clinicians in national efforts to address the opioid crisis and promote the importance and adoption of patient-centered multidisciplinary care.

Chronic Opioid Prescribing in Primary Care: Factors and Perspectives

Abstract: BACKGROUND: Primary care clinicians write 45% of all opioid prescriptions in the United States, but little is known about the characteristics of patients who receive them and the clinicians who prescribe opioids in primary care settings. Our study aimed to describe the patient and clinician characteristics and clinicians’ perspectives of chronic opioid prescribing in primary care.
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