The campaign to stop the “Opioid Epidemic” reaches into every aspect of healthcare, from the exam room to the hospitals, pharmacies and homes of people who live with pain every day. In reaction to this crisis, the Centers for Disease Control (CDC) published their Guideline for Prescribing Opioids for Chronic Pain to be used by Primary Care Providers as a tool in managing patients with pain (CDC, 2016).
According to the Guideline, all opioids must be converted to the morphine milliequivalent (MME). Additionally, the morphine milligram equivalent should not exceed the mandated 90 mg daily dose when converting opioid doses from one medication. How is the prescriber efficiently and effectively converting medications into MME? The CDC has worksheets and apps to assist (CDC, 2019), but these are just estimates for the prescriber. No two apps will give you the same conversion dose (Fudin, et al., 2018). Prescribers now feel pressure by multiple federal, national and local agencies to comply with the Guideline despite their specialty, be it primary care, pain management or any other specialty.
Since the publication of the Guideline, healthcare providers, hospital systems and insurance companies have translated those recommendations into rule of law and have handed down mandates to match the recommendations. Subsequently, Opioid Stewardship Committees (Gallegos, 2019), Opioid Free Emergency Rooms (St. Joseph’s Health, n.d.) have been created, while the amount of opioid prescriptions has dropped dramatically. Furthermore, states have updated laws to reflect more restrictive practices for prescribing opioids. Pharmacies have reacted with new policies, increasing scrutiny and release of opioids. Insurance companies have reacted by limiting, tapering or denying opioid treatments and prescriptions out of bias and fears of lawsuits. Additionally, coverage of opioid prescriptions is questioned, regulated and even denied when prescribed by a physician or healthcare provider not deemed a specialist in pain management.
Increased scrutiny regarding the number of prescribed opioids and the difficulty with MME and pain management regimes is tangible and concerning (Fudin). Ethical questions of decreasing established AND appropriate regimes for chronic pain patients looms over all areas of healthcare. How can one abide by the Guideline while providing appropriate care to new and well-established patients? Where has the ethical compass of do no harm gone and how do we get it back?
Hospital systems endorsed and enforced a decreased number of opioid prescriptions for all painful conditions, acute and chronic (Gallegos, 2019). Healthcare providers (HCP) in primary care settings are affected as well, impacting the relationship between patient and healthcare provider. Insurance companies have become more involved, starting with step therapy, moving towards mandates of number of opioids prescribed, and now to rapid tapering.
Many states legislatively limited the amounts of opioids prescribed (strength and quantities for a specified time period) and mandated opioid education for prescribers. Prescription monitoring programs (PMP) track the number of prescriptions filled by patients, with some patients finding themselves under scrutiny for using multiple pharmacies when the real issue is finding a pharmacy that has the medication as well as a pharmacy where the cost is within the means of the patient. Outliers are identified and targeted for scrutiny and possible investigations.
Prescription monitoring programs (PMP) also track the number of opioids prescribed by providers. The prescribers’ fear of investigation is tangible; suspending licenses, subpoenas for medical records, loss of income and imprisonment (Dineen & DuBois, 2016) is a real outcome. Many physicians have been caught in the web for years without findings or prosecution (depending on the findings). Medical societies have been educating physicians regarding their legal rights, mandated documentation and ways to protect themselves from prosecution and imprisonment (Dineen & DuBois, 2016).
Healthcare providers struggle with the ethical implications of following the CDC Guideline and watching their patients suffer with decreased function, psychological impairments, increased suicide rates, loss of wages and loss of self-worth while fearing prosecution and imprisonment themselves. The consequences of the Guideline interjects a chasm between the healthcare provider and patient.
- Centers for Disease Control and Prevention (2016). Guideline for Prescribing Opioids for Chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf
- Centers for Disease Control and Prevention. CDC Guideline for Prescribing Opioids for Chronic Pain. MME for commonly prescribed Opioids. April 17, 2019. Retrieved from https://www.cdc.gov/drugoverdose/prescribing/guideline.html
- Centers for Disease Control and Prevention. Media Statement April 24, 2019. CDC Advises Against Misapplication of the Guideline for Prescribing Opioids for Chronic Pain. Retrieved from https://www.cdc.gov/media/releases/2019/s0424-advises-misapplication-guideline-prescribing-opioids.html
- Dineen, K. & J. DuBois (2016) Between a Rock and a Hard Place: Can Physicians Prescribe Opioids to Treat Pain Adequately While Avoiding Legal Action? American Journal of Law and Medicine, 452.2(1): 7-52.
- Dowell, D., Haegrich, TM, Chou, R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMR Recommendations, Rep 2016;65(No. RR-1): 1-49. Doi: http://dx.doi.org/10.15585/mmwr.rr6501e1 External.
- Fudin, J., Raouf, M., Werzyn, E. & M. Schatman (2018). Safety Concerns with the Centers for Disease Control Opioid Calculator. Journal of Pain Research, 11, 1-4.
- Gallegos, A. (2019). Hospitals changing practices to curb opioid epidemic. ACP Hospitalist. Retrieved from https://acphospitalist.org/archives/2019/03/hospitals-changing-practices-to-curb-opioid-epidemic.htm
- St. Joseph’s Health. St. Joseph’s ALTO – Alternatives to Opioids (n.d.). Retrieved from https://www.stjosephshealth.org/home-page-articles/item/1908-alto-alternatives-to-opioids