New Washington State Opioid Guideline Charts Fresh Course for Treatment of Pain
An Interview with David J. Tauben, MD, FACP:
Co-Chair of the 2015 AMDG Opioid Guideline Committee; Chief, University of Washington Division of Pain Medicine; and Director of UW TelePain, a COPE-supported weekly telemedicine program on chronic pain
In June, the State of Washington’s Agency Medical Directors' Group (AMDG) released the 2015 Interagency Guideline on Prescribing Opioids for Pain. It is arguably the most comprehensive state guideline to address the complexity of treating and managing pain, and the benefits, limitations and risks of prescription opioids.
The AMDG’s initial guideline, published in 2007, was the first in the nation to attempt to reduce the prescribing of high-dose opioid medications associated with a rising national epidemic of misuse, abuse and overdose. Since then, Alabama, Colorado, Florida, Kentucky, Indiana, Ohio, New Mexico, New York, Oregon, Tennessee, and Utah are among the states that have adopted prescription opioid guidelines.
An update of the Washington guideline in 2010 focused on treating patients with chronic non-cancer pain through the principles of safe prescribing. It recommended a 120 mg daily morphine-equivalent dose (MED) as a “yellow flag” dose at which providers should seek consultation with a pain specialist.
While leaving in place the 120 mg/day yellow flag dose, the 2015 guideline finds that, “There is no completely safe opioid dose,” and that overdose risk doubles at even low doses between 20 and 49 mg/day MED, and increases nine-fold risk at doses of 100 mg/day MED or more. The guideline also emphasizes the use of non-pharmacological, multimodal therapies for all chronic pain patients.
Development of the guideline was a collaborative effort that involved medical directors and health policy staff from the State Agencies of Corrections, Health, Labor and Industries (for workers’ compensation), and the Health Care Authority (for Medicaid), along with healthcare providers specializing in pain medicine, psychiatry, family medicine, internal medicine, and other fields.
As the U.S. Centers for Disease Control and Prevention (CDC) begins the development of a national guideline, COPE interviewed Dr. David Tauben, MD, to find out more about what sets the 2015 guideline apart and how it could help clinicians nationwide.
Dr. Tauben has been involved in the AMDG since 2007, and served as its co-chair in 2015.
Q: Why do primary care doctors need to know how to prescribe opioids safely?
Pain is the number one reason people seek medical care for something other than a preventative check-up. Patients are driven by pain. Seventy percent of patients in everyone’s practice report pain, and at least 20 to 30 percent have chronic pain. It is also unbelievably expensive to treat pain poorly, and doing so leads to unimaginable suffering.
Q: What is the most significant change from the 2010 AMDG guideline?
We did not change the dose [i.e., the prior recommendation to seek expert pain consultation at a dose of 120 mg/MED daily] to underscore the fact that there is no safe dose. Above 120 mg/day, your patients are at far higher risk than at 100 mg, which is higher than at 50 mg, but there is still a doubling of risk at even low doses.
So we decided not to go with some artificially contrived safe dose. The issue is not how much opioids you should give, but what to consider as an alternative or in addition to prescription opioids. The major change in the guideline is a much more detailed discussion of alternatives.
We say unequivocally that opioid medications are useful for acute pain, and that we have a high degree of concern when they are used for chronic pain unless one can document improvement in function and quality of life for the patient.
Q: How can this be documented?
A: Improvement is all about function and quality of life. The pain intensity score that we have relied on in the past is less important than how the patient lives their life and feels quality in their life.
In terms of measurement, there are ways to get at “meaningful improvement,” but it is a challenge to know just what that metric should be. It would be nice to have a “quality-of-life” blood test or a “high-function” biopsy. They don’t exist.
The challenge of pain is being able to quantify and objectify the human experience. Nonetheless, there are a number of different options for measuring meaningful improvement. And we do know that many patients who are on a lower dose — or who come off opioids entirely — say that they feel better and their pain is no worse.
Q: What are the alternatives to opioid medications for chronic pain?
A focus primarily directed toward killing pain is very often not going to succeed. The best evidence-based alternative to prescription opioids is self-management — no drugs at all. With this guideline, we are reframing the experience of pain as one that a person can move past and have a high-quality, productive, satisfying life in the face of pain.
It can be done without meds, with a variety of psychological training, with mindfulness techniques, with graded exercise programs to overcome the fear of pain which is often the most debilitating aspect of pain.
We can help people with persistent pain overcome catastrophic thinking — believing that their life is ruined and only with the elimination of pain will they have a life again. We can reduce the suffering that goes with pain, but we are not going to reduce suffering with opioids alone.
With excellent, comprehensive, affordable care, patients with chronic pain should be able to receive treatment that allows them to manage pain and get back to life.
Q: What else is new in the 2015 guideline?
A: The guideline now includes children and adolescents, patients who are on chronic opioids and have a new medical or surgical problem, pregnant women, older adults, and cancer survivors who still have pain. It talks about how to reduce doses, how to identify addiction when it occurs, and how to best treat that addiction. So we’ve broadened the scope quite a bit.
Q: What, if anything, were you disappointed with in the 2015 guideline?
A: We did our very best to find published validated evidence, but the lack of scientific evidence for answering many of the key questions was discouraging. For instance, is there a safe dose? Is there a formula to reduce dose or taper patients? Is there a straightforward and well-established approach to manage patients with pain after their cancer is cured?
There is no evidence available that addresses duration of prescription opioid use, or how to manage developing tolerance, or how to assist patients who have developed a dependency of opioids when they’re following the prescription as offered, and hence are not addicts. We encountered many full stops, where there was not enough evidence.
Q: How did you address those situations?
A: The consensus of clinicians still matters, and we brought together broad representation from all across the State of Washington to come up with our own recommendations. We put together clinical experience, existing standards of care, and applied the science of neuroplasticity that examines changes to the nervous system and the time it takes for more permanent changes to take hold.
Q: Can Washington State’s AMDG Guideline lead the nation in addressing chronic pain and use of opioid medications?
A: Yes, for a couple of reasons. We met the highest standards of medical guideline preparation, established by the Bree Collaborative [an advisory body established by the Washington State Legislature to analyze evidence-based best practices in health care]. We met recognized criteria for the guideline to be meaningful, unbiased, based on standards of evidence, and developed through established processes. That characteristic is extremely important. Any group of so-called experts can produce guidelines.
The AMDG guideline also reached a point of comprehensiveness that doesn’t exist elsewhere. It is not just about opioid drugs, but about taking care of pain in a setting where opioids are being considered, and making changes in practice.
Q: What would you like to see happen with the guideline?
A: I’d hope that they become standard clinical practice. People need to be aware that they exist, to consider them important, and to use the guideline to change the way they practice, because it is so practical and deals with such common medical practice encounters.
Editor’s note: You can find links to a range of tools to help guide the treatment of patients with chronic pain in the AMDG Interagency Guideline on Prescribing Opioids for Pain; the free online CME COPE-REMS; and UW TelePain, a weekly telemedicine program on chronic pain.