Will the new CDC guidelines for opioid prescribing be helpful in changing your prescribing practice?

College of Physicians and Surgeons of Alberta CPSA, Designing Quality, Designing Quality Blog 14 Comments

The Centre for Disease Control (CDC) recently issued guidelines that reduce limits to appropriate and safe opioid prescribing for chronic pain patients. While awaiting the updated Canadian guidelines, College Council endorsed the CDC guidelines in May, signaling a fundamental change in thinking.

Evidence shows us that long-term use of opioids to treat chronic pain may not be as effective as other options, and may pose a serious risk to our patients. Physicians have to have tough conversations with their patients about what they can and cannot accomplish with opioid treatment, and encourage safer and more effective options.

Click here to visit the Opioid Prescribing Forum page.

We invite you to share your comments below.

“The new CDC guidelines are a good opportunity to open this discussion with our patients, set clear boundaries, and move
toward a safer, more appropriate treatment plan.”Dr. Monica Weller, CPSA Senior Medical Advisor

About Dr. Weller:
Dr. Monica Weller, a rural family physician for 28 years, brings office and hospital based clinical experience, including teaching medical students and mentoring residents. Dr. Weller supports physicians as a Senior Medical Advisor with the College.

14 Comments on Will the new CDC guidelines for opioid prescribing be helpful in changing your prescribing practice?

Dean Grant Baker said : Subscribe Mar 06, 2017 at 4:54 PM

Any medical scientist that states, "mindfulness", reiki, acupuncture or CBT; should lose their scientific medical license, the right to call themselves a medical scientist and should be re-labled: Quack.

mindfulness and wholly disredited CBT and, acupuncture? Seriously?

Some scientists.

    Deon Louw said : Subscribe Sep 05, 2016 at 11:01 PM

    My practice is devoted to management of chronic pain patients, with an accent on spine intervention and headache. The International Classification of Headache Disorders states that regular use of opioids is a major risk factor in the chronification of headache: "Diagnostic criteria: Headache fulfilling criteria A, C and D for 8.2 Medication-overuse headache Opioid intake on ≥10 days/month on a regular basis for >3 months Comment: Prospective studies indicate that patients overusing opioids have the highest relapse rate after withdrawal treatment." I have always wondered why our non-headache chronic pain patients are often not initially prescribed intermittent opioids, as this should reduce tolerance and the albeit unusual, but real, risk of hyperalgesia. Might be an interesting study to assess generalizability of the headache literature? I don't think anyone is suggesting we all do a hairpin turn from narcophilia to narcophobia. Nevertheless, it is a quotidian disappointment to see patients on high doses of opioids, sans Opioid Risk Tool, contract or urine screening. A minority of these admittedly complex referrals have demonstrated significant functional improvement, and too many highlight the porous boundary between psychological perturbations and pain. Many of our patients suffer enormous physical and/or mental anguish, and it is difficult to sometimes admit that certain situations are therapeutic 'wastelands'. I am sure it also happens that at times we channel Pygmalion, where we treat our patients with such care and precision we can't but anticipate good results? I am optimistic the dialogue initiated by the College will help us navigate the necessary equipoise.

      Esprin Reddy said : Subscribe Aug 18, 2016 at 10:47 AM

      The comments made by my colleagues are very pertinent and relevant to the complex problem of treating non malignant chronic pain. Many years ago I participated in a study whose aim was to determine which type of patients used opioid narcotics for chronic benign pain. We found that a significant number of these patients suffered from depression and other psychological issues due to previous history of abuse in childhood . There was also a concomitant higher incidence of chronic anxiety and stress and insomnia. We concluded that many patients needed a psychiatric evaluation as part of the treatment of chronic pain. The second point is that in many instances no specific surgically treatable cause could be found in these patients and even after appropriate surgery many of the patients continued to have chronic pain. The third point is that many of the patients have already tried non - steroidal and other over the counter pain medications without relief before coming to their physician . The ideal would be for all these patients to be evaluated by a multi-disciplinary chronic pain clinic before receiving opioid narcotics . However this does not appear to be a practical solution as access to these clinics are very limited. There are some patients who are prescribed opioid drugs appropriately to function and perform their work and or daily activities of living , despite having severe chronic pain . While this is a small group of patients , I do not think , they should be denied opioids if they are using them in an appropriate manner.

        David Lardner said : Subscribe Aug 17, 2016 at 7:23 PM

        As an anesthesiologist dealing predominantly with acute pain, I am concerned that the vilification of opioids for chronic pain will have a spillover effect in the management of acute surgical pain. I would hate to see us go back to the 70s and early 80s when acute surgical pain was under treated. With the push to earlier discharge of surgical patients postoperatively, it is important for us not to withhold prescribing opioids to these patients because they are at home rather than in hospital.

          d said : Subscribe Oct 27, 2016 at 5:59 PM

          This reply is addressed to the College of Physicians and Surgeons. Because of the demonization (vilification) of Oxycodone, I can't even get my prescription for 60 mg of Codeine switched to the equivalent dose of Oxycodone, which is only 8.33 mg of Oxycodone!! WELL BELOW the guidelines of <50 mg equivalent of morphine. No doubt I am just another junkie aboriginal wanting a drug with a dirty name! I understand that drug addicts and drug dealers have made things difficult for everyone, I get it, but to equate humane pain relief to drug addiction, and to deprive responsible patients from even low does opioids is inhumane at worst, Veterinarians don't even treat dogs this way!!! Oxycodone was invented for people like me who can't tolerate Morphine. Codeine is converted into Morphine, whereas Oyxcodone is not! I was administered Morphine after major surgery, I vomited immediately, and I was sick for a week after I got home! I have tolerated years of nausea on Codeine, and found out that Oxycodone does not make me sick, I found that out from being prescribed Percocet 10 mg for dental pain. This is the only reason I had asked to be switched, and not even to a higher dose, just an equivalent dose! I wonder how many people like me who have never bought drugs of any kind off the street will be willing to risk their lives buying it illegally because opioids are becoming impossible to obtain legally??? I considered it just one time with one look on the Internet last week, but I won't because I AM AFRAID TO DIE from illicit drugs, and because I am not going to contribute to the criminal elements of drug dealers!!! I am not a criminal, nor do I want to get high, I just want my pain to be tolerable, and to be able to go back to work! I wonder how many people like me ARE NOT AFRAID TO DIE? How many people like me are you going to push over the edge??? I JUST WANT TO KNOW!! ps, I am willing to live with pain that is tolerable, I am a mentally well adjusted woman who realizes that life will never be perfect, I just don't want to be sick all the time, nor should I be asked to tolerate pain that not even a Veterinarian would subject a dog to!!!! To those of you that sit behind your desk, with your smug attitudes towards chronic pain patients and opioid pain medication ought to keep in mind that YOU TOO may be subject to chronic disabling pain some day! Then what? Will you then have an ounce of compassion??

            Robert Hauptman said : Subscribe Aug 17, 2016 at 7:27 AM

            I appreciate the comments that have been posted so far and I also appreciate the leadership of the CPSA in this area. However, I think what often gets lost in the discussion is that there are really two issues here and two distinct patient populations. The two issues are really how do we manage patients with chronic pain effectively and how to we manage patients with substance abuse disorder. The question of how to effectively manage chronic pain patients is complex. There are no Canadian or American guidelines on how to manage chronic pain patients (although there are guidelines on how to use opioids in these populations). Although the use of opioids in this population is controversial, there is clearly evidence for efficacy of opioids in some patients with chronic pain. There has been much discussion regarding other forms of pharmacological and non pharmacological therapies for chronic pain but unfortunately most of these also have limited efficacy. For example the Cochrane review of amitriptyline for fibromyalgia and neuropathic pain found limited high quality evidence for efficacy and a recent published trial on mindfulness and CBT for chronic low back pain found only 1 in 4 patients respond to this therapy. It is clear there is no one size fits all treatment for chronic pain. To address the issues around safe management of chronic pain patients the Pain Society of Alberta and the AMA Section of Chronic Pain have developed a Provincial Pain Strategy which is available on the Pain Society of Alberta website. This strategy has already been presented to government. As well a consortium of pain consultants from across Canada have sent a letter to the registars of all the provincial Colleges outlining strategies for the safe management of chronic pain patients and the safe use of opioids. This September at the AMA RF forum in Calgary, the AMA Section of Chronic Pain has been given an hour session to discuss the safe management of chronic pain patients. We welcome the opportunity to discuss the issues with our colleagues across Alberta. We all agree that we need to tackle the issues around opioid abuse. However we also do not want to limit access to patients with pain who might benefit from these medications. Already many pain consultants, including myself, have seen the backlash of the fears of prescribing opioids in that many of our patients find it nearly impossible to find family physicians willing to take them on. Also, it is my understanding, that more and more Alberta physicians are choosing not to get a triplicate prescription pad. The AMA Section of Chronic Pain and the Pain Society of Alberta believes that the solutions to these problems should include the following: 1) Responsible prescribing of all medications of abuse including opioids, BDZs, stimulants, gabapentin, pregabalin and buprion. 2) Dedicated undergraduate training in chronic pain management and addiction management 3) On going education of physicians on the management of chronic pain and addiction disorders 4) Boundary setting when prescribing opioids in all patients including urinary drug screening and limiting dispensing intervals 5) Improved funding for non pharmacological management of pain including psychological services 6) Better access to certified addiction specialists in the province Does responsible prescribing work to reduce negative consequences of opioid prescribing? In the Journal of Pain, a study was published a few years back on "Project Lazarus". This project, done in North Carolina, demonstrated an 80 percent reduction in death rates from opioids with physician and community education despite no change in dispensing of opioids in the same community. The AMA Section of Chronic Pain and the Pain Society of Alberta, both look forward to working with stakeholders and the CPSA to ensure the safe management of patients with chronic pain in Alberta while reducing unintended harms from opioid misuse. Robert Hauptman MD Pain Consultant Past President AMA Section of Chronic Pain and Pain Society of Alberta HealthPointe Clinic

              Das Madhavan said : Subscribe Aug 16, 2016 at 1:51 PM

              Glad to see this cancerous physician issue is taken up seriously by the CPSA, hats off to the initiators. Yes CDC guidelines are quite helpful. But the question we are reluctant to answer when a behavior is flawed is " Who and what perpetuates the flawed behavior ? ". We are unconsciously / subconsciously avoiding this key question, since the answers might put us, the prescribers in the limelight, and in a difficult predicament further projecting our own ethics in prescribing. Hakique and Scott has outlined some of the key issues already. My suggestion is to focus on negatively reinforcing the practice of ignoring the evidence-based approach. As yet there is hardly any evidence for long term prescription of opioid pain killers. My suggestions in nut shell are as follows: 1). Adopt the 'Prescription Monitoring Program Registry' model from the New York Health https://www.health.ny.gov/professionals/narcotic/prescription_monitoring/ 2) Mandate that the particular medication is not prescribed to those already having a history of addiction to that type of drug. 3) To dispose a patient asking for a pain killer is at least 10 times faster done by giving a prescription, than to engage him/her in addressing the abuse/ health hazards of continued use of the drug, hence without a second thought perpetuating our unethical practice. 3) Mandatory registering of all physicians in a 'special category prescribing' registry which is monitored automatically ( electronically as the prescription is created, prompting status of the patient's addiction potential). 4) Impose monetary fines for those physicians ( as with the model of PMP in NY, which is very high ); an easier way to improve the financial fabric of the CPSA too, which in turn can be used for further training of physicians in this regard. 5) By all means prevent/ limit the current practice of allowing non-physicians prescribing addictive opioid pain medications through coordinated legislation. 6) Publish the names of those physicians who have the highest rate of prescription of addictive drugs; and those who prove to be diligent . This is a powerful means of both negative and positive reinforcement respectively ( though may not be welcome by many of us ). Last but not the least, please do not forget this iatrogenic problem is significantly exhausting several of the psychiatrists / addiction specialists and huge amount of resources. If we collaborate and work together, it could be another pioneering initiative from Alberta to later spread to other provinces.

                Jim Adams said : Subscribe Aug 16, 2016 at 12:03 PM

                When I was advised to attend a conference in Nashville on opiod prescribing by the CPSA, the conference leader started the three day seminar by asking doctors where they were from. The other 12 doctors were all from the USA and when I said I was from Canada, he stated, "The number one cause of drugs on the streets in the USA is physicians. BUT, in Canada the number one cause is mofia and street drugs. Physicians are NOT the problem in Canada due to the triplicate programs and rules." Nice to know that physicians aren't the problem, but the College doesn't accept that and goes with US statistics and applies that to physicians here. When serving overseas at various hospitals, we have very little access to narcotics and patients surfice with Ibuprofen and Tylenol. In North America and Europe we seem to think pain must be treated and not allowed to occur and thus we encourage narcotics and analgesics. If you take away narcotics, you only encourage more marijuana or other drugs to take their place. Mankind will always seek pain relief rather than deal with the spiritual and emotional issues causing them.

                  Noel Hershfield said : Subscribe Aug 16, 2016 at 12:03 PM

                  So many patients that I saw when I was an active practice, were referred for chronic abdominal pain. Many of them, too many of them were already taking narcotics for the relief of the pain, the cause of which was unknown. Therefore I did whatever appropriate investigation we could find based on a careful physical examination and history. At least 20% of the patients that I saw suffering from abdominal wall pain and I reported that series of cases. If we could not find the causes of pain tried everything that was possible in order to get relief before continuing narcotics. This included exercise, acupuncture, physiotherapy, and on occasion psychotherapy, and many other strategies that are freely available now in the many wellness clinics that are cropping up in our city. Of course the solution of the problem may be the legalization of all narcotics. This has occurred apparently for the last 15 yearsin Portugal and the crime rate is down and not only that the demand for narcotics has decreased! They offer treatment rather than punishment for those that are involved in narcotic use.

                    Brian Knight said : Subscribe Aug 16, 2016 at 10:08 AM

                    We do have to accept that the prescription of opioids in chronic pain remains controversial and we have to accept that some of the opioids being abused on the street are coming from prescriptions written in good faith by doctors. At the same time proscribing one aspect of chronic pain practice without a parallel increase in the resources available to treat these patients and without increasing the education of physicians in treating pain is short sighted.

                      Karen Mazurek said : Subscribe Aug 12, 2016 at 12:06 PM

                      The CPSA recognizes that there are many factors contributing to this crisis. Our jurisdiction is over the actions of individual physicians and, as a result, we are developing strategies to inform and support physicians with prescribing data and educational support. We want all physicians to prescribe responsibly. Having said that, I completely agree with the above comments regarding advocacy for more resources for patients and physicians for treatment of opioid use disorder and non pharmacological treatment for chronic pain. CPSA's mandate is to ensure patients receive high quality care from physicians. We know physicians need access to these resources to help their patients. We can't control resources but we can exert influence and we are fully prepared to add our voice to the discussion with stakeholders to try to improve access to these treatments.

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