Prescribing Guidelines—Prescribers, Patients, and Pain Care

Author: Stephen Ziegler

The terms prescribing guidelines and prescribing rules are often used interchangeably although they really have separate meanings. Guidelines, by their nature, are voluntary recommendations. Whereas prescribing rules are mandatory. It’s important for prescribers to be aware of what exactly the rules or the guidelines are in their state. The recent history of prescribing guidelines started in Washington State.  A pilot educational project ended up being a rule that any time a chronic non-cancer patient receives 120 mg morphine equivalent dose or more per day that will trigger the necessity for the prescriber to secure a pain consultation unless exempted from the rules. And so, this approach heavily emphasized dosage thresholds as a key part of the policy. That part, dosage thresholds, has essentially spread across the United States in various forms among different states; some states have 60, some 120, some 100.

Prescribing guidelines were originally created to aid the practitioner and be combined with their knowledge and experience to provide an additional point of information. Unfortunately, states and other entities such as insurance companies are now using the guidelines for things other than clinical purposes. Oftentimes prescribers, being risk adverse, will reduce their prescribing and/or not want to take on chronic non-cancer pain patients. And although the CDC may recommend non-pharmacologic approaches to treating pain, the reality is that there may not be other modalities that are as effective as opioids or are covered by insurance. Denial of coverage is denial of care. And so, you have these lost souls that are people in pain with limited ways to go. A recent study found that only 12% of states medical boards had a plan in place about what to do if patients were to lose prescribers who can prescribe opioids to treat chronic pain. There is also reason for concern about the impact of current guidelines on the patient/provider relationship. What has happened now is that there are other people at the party, so to speak, and those are regulators. And so, it brings up certain ethical concerns concerning privacy and what is in the best interest of the patient. Pain treatment by its very nature is individualized and states that implement guidelines in the interest of reducing harm associated with opioids, whether legitimate or illicit, need to realize that one size does not fit all and a primary focus on dosage alone is problematic for a variety of reasons.

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