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]."