AMA Delegates Back Physician Freedom in Opioid Prescribing

CDC guidelines are well-intentioned but shouldn't restrict prescribing, they say

by Joyce Frieden

NATIONAL HARBOR, Md. -- The CDC's guidelines on the use of opioids for pain management are well-intentioned, but some insurers and pharmacists have used them to restrict providing and need to be discouraged from doing so, members of the American Medical Association (AMA) House of Delegates said Tuesday.

"This is a recognition that there are many patients we deal with daily who are outside the norms proffered by the CDC guidelines," said Bob Wailes, MD, of Rancho Santa Fe, California, a delegate for the American Academy of Pain Medicine. "The gist of this proposal is that the CDC guidelines have gone way too far and have been used as strict legislative and pharmacy benefit limitations.... We need to recognize by policy that there are patients who fall outside the guidelines."

Delegates approved a resolution that both applauded the CDC for "its efforts to prevent incidence of new cases of opioid misuse, addiction, and overdose deaths" but also urged the AMA to talk to pharmacy chains, pharmacy benefit managers, state insurance commissioners, and state medical boards and argue against putting blanket limits on the amount and dosage of opioids that physicians can prescribe.

"The AMA Opioid Task Force has discussed these issues extensively," said Frank Dowling, MD, of Islandia, New York, a delegate for the New York state medical society. "We're getting feedback from physicians around the state ... with physicians being punished, prescriptions not being filled, and patients left without medications. It's extremely harmful -- these medicines do work and care [needs to be] individualized."

Delegates also passed several provisions offered by Chad Kollas, MD, of Orlando, on behalf of the American Academy of Hospice and Palliative Medicine. One provision proposed by the pain medicine group, and approved by delegates, asked the AMA to affirm that some patients benefit from taking higher doses than suggested by the CDC guidelines.

Another provision from the group called for the AMA to advocate that "no entity should use MME (morphine milligram equivalents) thresholds as anything more than guidance, and physicians should not be subject to professional discipline, loss of board certification, loss of clinical privileges, clinical prosecution, civil liability, or other penalties or practice limitations solely for prescribing opioids at a quantitative level above the MME threshold found in the CDC guideline for prescribing opioids."

"As family physicians, we strongly believe in patient-centered care," said Romero Santiago, MD, MPH, of Sacramento, a resident delegate for the American Academy of Family Physicians, who spoke in favor of the provision. "It's important for us not to have a standard on MME equivalents ... It's important to advocate for the needs of our patients."

Scott Pasichow, MD, of Warwick, Rhode Island, a resident delegate for the Massachusetts Medical Society who was speaking for himself, asked that the MME provision be referred to the board of trustees for further consideration. "MMEs are part of Rhode Island state law right now, so there are places where a practice like this is enacted; I would just want more information on the effects of that being positive or negative on our patients as well as us as providers, before we come to the decision that we oppose this as anything more than guidance," he said.

Arlene Seid, MD, an alternate delegate for the American Association of Public Health Physicians, who was speaking for herself, agreed with Pasichow. "I work for a regulatory agency and the issue is, sometimes guidances are used to take in drug dealers, especially those of us who do not adhere to good practice," she said. "I ultimately would be supportive of this [provision] properly crafted, but [for now] I would be in favor of referral."

However, the delegates ultimately voted against referral. "This is extremely timely and needs to be addressed," Wailes said. "Please vote against referral."

Sherif Zaafran, MD, of Houston, speaking for himself, said that he is a member of a pain management task force being convened by the Department of Health and Human Services. "Draft comments will be coming out in a couple of weeks and will very specifically address the misinterpretation of the CDC guidelines," he noted. "This is really timely because the comments from the AMA will be extremely important in weighing in [on the issue]."

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Comments

It's about time. I applaud the AMA for standing up for Doctors & Patients nationwide today. So many have been harmed by draconian CDC Guidelines. No where in the practice of Medicine is a "One Size Fits All" approach deemed appropriate. I hope to see Insurers taking heed of this now as we have seen particulally in the past year many Insurers who are putting an 90 Mg MME Opioid Dose Threshold on the coverage of all Opioids which in my opinion should be considered the "Practice of medicine without a license." We need to begin to move away from absurd MME thresholds and back into the proper practice of treating patients on an "Individual" basis with Opioids and any medications for that matter. Thank you AMA.

— Debra Woodard
It is about time physicians and clinicians with prescriptive authority take back the responsibility of treating patients and using medications that are appropriate for the patient instead of government agencies tell everyone how to practice medicine.

— Janet Colbert
More overdose deaths last year than the entire Viet Nam War. The FDA approves sufentanyl 10 times stronger than fentanyl. Yesterday the AMA President was quoted using the same verbiage as Big PhRMA- undertreatment of pain. And now a campaign to undo the CDC guidelines which until they were released doctor education was coming from the drug companies. We need full disclosure - is this funded by Big PhRMA.

— Janet Colbert
Too bad the AMA is not supporting the ALTO program - Alternative to opiate prescribing in the ER. I have met with the teams that are instituting this into practice. They are dedicated to best practice for each patient. A PharmD is dedicated to the ER to collorabrate with the doctors. They have found IV lidocaine works better for kidney stones than opiates. I don't know anyone addicted to lidocaine. Grants are available to hospitals for initiating the program per the new Opioid Package signed into law. This surely is a better alternative than "here take these". Better for the patient - not the pharmaceutical industry.

— Kimberley Windisch, NP
I also applaud this move. Payers are attempting to create a binary world in medicine, one in which drugs can be classified into "good" or "bad" and treatment paradigms following a similar binary pathway. Not only does this thinking ignore the individual differences in patients, but it also is an attempt to eliminate the need for clinicians to utilize their knowledge, training, experience, and understanding about the unique patients and communities that we treat.

— DTC, pharmacist
To Janet Colbert - it depends what numbers of overdose deaths you are referring to because it is certainly not more deaths due to opioid pain medications. There were 72,000 overdose deaths which includes ALL overdoses from ALL classes of medications. Overdoses from opioids were 49,000 and within that group only 19,354 were from opioid pain relievers. Deaths from fentanyl (illicit) totaled over 29,000, heroin almost 16,000, and cocaine 14,500. (One death could be counted in more than one category, numbers from NIH.) Vietnam war deaths totaled 58,220 versus 19,354 deaths from opioid pain medications. By the way, there were 10,684 deaths due to benzodiazepines, should the CDC mandate doses and days of therapy for those also?

I have no connections with or any payments/gifts from any drug manufacturer. My only concern is that in the national noise of the “opioid epidemic” the focus is on those who abuse opioids and I want to make sure that we still hear the cry of the patient who needs pain relief and who does NOT abuse the medications.

November 14, 2018— Andrew Johnstone
There is a huge difference between a compliant patient who is supposed to take 4 to 6 oxycodone pills per day, and 3 alprazolam per day, and has a pain/spasm flare, so takes 8 oxycodones and 4 alprazolam, versus a drug-abuser who is supposed to take 4 to 6 oxycodone pills per day, and 3 alprazolam per day, and decides to take 18 oxycodones, 10 alprazolams, some amphetamines they got from a dealer, a couple pills their neighbor gave them they aren't sure what are, then top it off with a pint of whisky.

Putting them in the same category isn't a good way to generate sound public policy decisions.

This is the first thing the AMA has done in a long while that I actually find positive..!

— Alexander Babayants
i am an expert in addiction not pain management, so i dont believe in opioid treatment of chronic pain........never seen working, they still in pain and/or already addicts.......and i do agree that CDC/DEA/USA as usual overshooting......the community have lost the precious part- medical care, .......too many docs were eliminated and ignorant agencies have too much power in those decisions.....people have died bec no docs. BTW most OD from Fentanyl nor percs and docs kept them alive. in FL OD quadrupled after docs were out

— Andrew Johnstone
"so i dont believe in opioid treatment of chronic pain........never seen working, they still in pain and/or already addicts" - you must live in a different reality than some of the rest of us. I've seen MANY patients who feel better (no, not 'pain free', but 'tolerable') on narcotics, when no other regimen got them even to that point. They are able to function at home and at work, when prior to or without their medication they are so distracted by pain they can't function.

I'm not sure why that is somehow "bad" to accomplish....

— Janet Colbert
DTC pharmacist - I am sure you are aware that 8 of 10 heroin users begin with the highly addictive not so innocent pain pill. There have also been many deaths as a result of - Taken as Prescribed. I find it questionable that the AMA has had no voice until the bottom line of the drug companies might start to be affected. Alternatives to opioid prescribing would be a benefit to all. Maybe you should read the book STOPPNow to be aware of the manipulating that was and still is perpetuating the opiate epidemic.

— Sherry collins
I think that the AMA has this exactly right. There are in fact Doctors, Pharmacists and "SOME" pain patients who have abused the system, however "THE SYSTEM" has failed many pain patients, not to mention the told and UNTOLD pain patients that have taken their lives due to feeling abandoned and in horrible pain, by "THE SYSTEM" that should have been there to protect them! This is something that cannot be undone, SADLY. I hope things for current pain patients in 24/7 pain, unable to live normal lives get better from here and they do not feel compelled to do the same thing. Pain practices have to stand up for the "REAL" patients before it is to late and not suffer for doing so.

— Dr with chronic pain
Ms. Colbert, can you tell me how many of those 8 of 10 heroin addicts started their journey with a legitimate prescription? I'm guessing it is a low number.

— Elizabeth McConnell
Thank you, AMA, for advocating for patients AND common sense. As is always the case, knee-jerk overreaction is the order of the day when legislators are involved.
Let us not forget that more people died from alcohol abuse last year than drug overdoses. Perhaps we should spend some quality time looking at the bigger problem of rampant alcoholism.

— gina c
Thank you. The next step was suicide for many chronic pain patients tapered off medications they have used safely for decades. Forced tapers of these medications have already caused many unnecessary deaths and suffering. Addicts can get better. Our diseases are for life. It's not right to punish a group of patients to benefit another. That is between patients and their doctors not the govt. Thank you. You saved many lives today.

 

— gina c
I think we need to put this into perspective and some are quoting ridiculous figures that include illegal drugs. I guess they don't realize cancer patients and severe lifelong painful illnesses are being refused pain relief. Take care of the addict,fine. But do not forget about the rest of us who did nothing wrong but get sick. I've been on my medication for almost a decade and a half due to things like CPRS, a failed lumbar fusion, and now RA. Why am I denied care now because of people that abuse their medication or take illegal drugs? Two different populations of patients that should receive different treatment. Thank you AMA for finally taking up for patients and the doctors that help us. I don't want to be housebound any more or my dr threatened by the CDC so he can't treat me. The govt has absolutely NO place in my doctors office. Thank you.

— Kathryn Argiro
Janet Colbert,
I have to step in here and say that your information is incredibly far from accurate. I hope that you are not responsible for caring for or treating anyone with chronic pain. Maybe it will take a day when you need these medications yourself when you will finally understand. The propaganda you are talking about is commonly heard in recovery, AA, NA, etc. Except it does not apply to those who are not addicts. No, not everyone who takes an opiate prescription becomes addicted. No, not every opiate addiction becomes a heroin addict, either. Each person is entirely different from the next. To put everyone in the same boxes is close-minded and ignorant. Millions of people depend on opiates (are not addicts, they depend on it) in order to relieve some level of pain so that they can live their lives without suffering. If you can imagine for one minute to be in excruciating pain every single second of every single day. Maybe you might have some compassion why people need relief like this. If there were non-opiate alternative medications or treatments available that worked, they would all be doing that instead. For some reason, that has not been made available by our pharmaceutical companies... Yet. I'm guessing when it does, it will not be cheap. By then, everyone will be forcibly taken off of their meds and have no other option. Pretty shady, right? That's my theory in all of this. Mark my words. Look how well Suboxone is doing right now. Coincidence? I think not. Open your mind, Janet. Not everyone is a junky. But the government is in bed with Big Pharma. Has been for a long time. It's worse than ever these days.

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