Apologies to Hamlet for borrowing his line to open this post. When I wrote a few weeks ago, I said that one of the things I’d be talking in September and October would be doctors’ need to turn to current science in deciding about opioid prescribing. That is the subject of today’s post.
“There is a lack of high-quality guidelines on opioid prescribing.” -CDC staff, testifying before Congress, May 2015
Today, every state in the country has opioid prescribing guidelines in one form or another. The State of Washington pretty much led the way in forming the guidelines which states like California, Pennsylvania, Florida and other jurisdictions have since put in place. In addition, medical societies, workers’ compensation insurance carriers, medical specialty associations and other groups have their own opioid prescribing guidelines, which sometimes go farther than the guidelines of the state where an individual member-physician practices. In addition, there are documents which compare all 50 states’ prescribing guidelines; there are papers, studies, speeches, initiatives, bills, calls for action and other efforts to ensure patient safety and medical legitimacy in opioid prescribing. And, there are multiple law enforcement agencies in each state, there are 50 different medical boards across the country, and of course there’s the DEA. The interpretations of prescribing guidelines by members of all of these agencies might vary substantially, even within the same state.
Amid all that, amid that plethora of paper and deluge of deliberation, the CDC still boils it down to the conclusion that “there is a lack of high-quality guidelines on opioid prescribing.”
Let’s figure the CDC is right. How to explain the lack of high-quality guidelines if there are so many, many sets of guidelines out there? The answer is that guidelines today only tell a physician what to do when he or she chosen to prescribe, instead of asking a physician to more carefully decide whether to prescribe at all, or whether to continue opioid therapy.
What today’s guidelines are missing, pretty much uniformly, in my view, is a thorough and careful, current and scientifically faithful discussion of the efficacy of opioid prescribing. If you look at today’s various sets of guidelines, their introductions and updates pay generous lip service to the notion that the whether of opioid prescribing is very important, but the guidelines themselves are still rooted in the view that opioids are generally safe and effective for chronic pain. The problem is, the view that opioids are generally safe and effective for chronic pain is being steadily and credibly challenged by new scientific evidence. So the guidelines, despite the good faith with which they have been drafted, are necessarily behind the times.
What is needed is a new approach, an “evidence-based” look, to use the term so in vogue now in medicine, enabling physicians to take a more careful and complete look at the medical and legal aspects of whether, not just how often or how much, to prescribe. Guidelines will not be the source of this information, because they’re reduced to paper or online documents, they are subject to lengthy legislative or administrative processes, and scientific studies and data continue to emerge after any set of guidelines is published. But that doesn’t mean doctors can’t gain access to the information they need. Clinically legitimate and legally compliant decisions on whether and when and how much and how often to prescribe opioids can still be made, if all the right ingredients go into the mix from the beginning.
More on that soon!