The Necessity of Ethical Guidelines in Opioid Prescribing

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By R Carter

Everyone knows that the US, as a country, has an opioid use disorder. Not a day goes by that this issue is not making headlines somewhere in the US. It has been declared a National Healthcare Crisis by the White House and as such, this elevates the issue to allow a more rapid response, by passing some of the usual checks and balances used when passing regulations to improve the health and wellbeing of the country.

But such rapid responses often overlook other issues in the rush to address the problem and in the wake of such actions there’s collateral damage which was not anticipated or expected. Take for example the 2016 CDC Guidelines for Chronic Pain Management, written based on data and research for acute pain management and opiate naive patients, the guidelines failed to address the unique problems of chronic pain patients. The nation’s healthcare systems subsequently forced tapered or terminated medication for millions of Americans with legitimate medical need, producing loss of income, increased pain and suffering, complications which led to sudden death or suicide. The CDC has since issued a clarification, but the damage has been done and many who were employable are now living on savings, Social Security or worse, on welfare and subsidies from the state.

Ohio’s new guidelines on prescribing opioids for subacute and chronic non-cancer pain went into effect December 2018. These guidelines are somewhat unique from the standpoint of Ohio being one of the first states to adopt specific prescribing guidelines for physicians who prescribe opiates for chronic non-cancer pain conditions. The State Medical Board of Ohio in May 2019, published a video to help inform primary care providers of these new guidelines which are intended for them.

When compared to prescribing guidelines adopted by other states, Ohio’s guidelines offer greater flexibility and autotomy for prescribers, allowing doctors to exercise a broader range of judgement for when and if minimum caps must be exceeded to accommodate chronic pain needs.

Ohio’s guidelines still follow checkpoints recommended by the 2016 CDC Guidelines for Chronic Pain Management which occur at 50 MED and 90 MED, but extend dosage limits to 120 MED and above when the clinician can document the need for doing so.

The guidelines are directed at Primary Care Providers not pain specialist. This is an important distinction, prior to December 2018 prescribers had no standards of care to follow for prescribing opioids, which greatly increased their risk for investigation or prosecution by a state medical board or law enforcement. These new guidelines codify a legal framework for treating non-cancer chronic pain with opioids, something the CDC guidelines did not provide. They protects doctors from accusations of inappropriate prescribing,  a tactic used often by some state medical boards and law enforcement in the over zealous attempts to thwart drug abuse.

The new guidelines do not compel primary care providers to prescribe opioids, as independent practitioners doctors can still choose to treat chronic non-cancer pain or not treat it, but when choosing to do so, it’s an all or nothing choice. Clinics and PCP’s may not selectively choose to treat some but not all patients with opioids who meet state standards. 

This is an important distinction which all chronic pain patient should understand. In our healthcare system today, every chronic pain patient taking more than 50 MED on a daily basis should have a PCP and a pain specialist providing care for them. In the event the pain specialist closes their clinic, discharges a patient inappropriately, the PCP is obligated to act as a fallback prescriber until the patient can locate a new pain specialist, essentially ensuring no break in medical care.

These are ethical standards recognized by a handful of clinics and physicians but not written into regulations and law by state medical boards. For this reason, the chronic pain community should lobby state medical boards to adopt such ethical standards, in writing, as a means of recognizing the distinct difference between chronic pain treated with opioids and individuals treated for opioid use disorder.

As the chronic pain community is well aware, many chronic pain patients are inappropriately labeled as drug seekers and or having an opioid use disorder in the absence of a formal exam and workup to support such claims, leaving some legitimate patients stranded without access to medical care. Such events lead to complications which can threaten the individuals’ life and in some cases has lead to sudden death or suicide.

In a healthcare system which has a responsibility to treat chronic non-cancer pain disorders, one which has been locked down so tightly that it is impossible to simply make an appointment with a new prescriber without a referral, having a Primary Care Provider as your backup for when an unexpected and unethical act occurs, becomes a necessity to protect the public’s health.

Having ethical guidelines lines for protecting chronic pain patients is as essential as having guidelines to prevent opioid abuse and opioid use disorder, after all, these are the primary concerns which have driven government to take actions which has resulted in the deaths of chronic pain patients.

It seems rational therefore, that guidelines which protect the public from a healthcare system which overreacts, is no less of a concern than protecting the public from a healthcare system which has over prescribed. Despite the fact that fewer have died as a results of being denied access to healthcare, those who have not are still treated as 3rd class citizens or worse. Individuals who are a victim of a problem they did not create nor do they contribute to. We are talking about hard working Americans who want nothing more than to hold down a job, pay their taxes and take care of their families. Throwing the baby out with the bathwater has to stop and I see no way of correcting this problem until states start recognizing the need for ethical standards which address the unique problems faced by the chronic pain community. 

Ethical guidelines protecting people from a healthcare system too quick to profile them as opioid abusers, written into the standards of care, becomes an essential element of protecting the health and wellbeing of a public. Our tunnel vision on stopping opioid abuse can no longer afford the continued collateral damage it is causing. It is after all, the primary mandate of every state medical board to protect the public from healthcare gone awry, including those with chronic non-cancer pain.

If you are a healthcare provider, concerned citizen or chronic pain patient wanting to engage in solutions or be more informed about physician care, forced tapering or termination of pain medication, then consider this free webinar open to the public on July 22, 2019.

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