As government agencies, medical groups, hospitals, and pharmacies have tried to cut back on opioid prescriptions, they’ve wrestled with how to best do so. Should they restrict the number of days a prescription lasts? Should there be a cap on the total strength of the dose? What kind of exceptions should be made?
A new report issued Thursday by the National Academies of Sciences, Engineering, and Medicine outlines a framework for prescribers and others to develop their own plans for acute pain, without offering any direct recommendations itself.
The report says any group drafting prescribing guidelines should consider a host of factors: the evidence, or lack thereof, for using opioids versus alternatives for a condition or procedure; the downstream effects of any prescription, such as refill requests and the possibility that some pills will go unused; and the broader potential implications of their plans, including pain relief and improved quality of life, as well as harmful consequences.
It notes that the guidelines should not be seen as ironclad, and should allow for individual clinical decisions — a critical point at a time when many clinicians and others have argued that overly strict adherence to certain guidelines have harmed patients.
The committee also identified conditions and procedures for which prescribing guidelines should be developed or refined, including C-sections, wisdom tooth removal, low back pain, sickle cell disease, and migraines.
The Food and Drug Administration originally asked the National Academies to come up with a framework for developing evidence-based prescribing guidelines, but the committee that wrote the report took a broader approach, establishing a guidebook that any group can use.
“We realized that in addition to what the FDA might do, lots of other organizations are issuing guidance or positions for opioid prescribing,” said Dr. Bernard Lo, the president of the Greenwall Foundation and a former professor at the University of California, San Francisco, who led the committee.
The goal was to inject some consistency into a sometimes capricious approach. Depending on where they live or which hospital they go to or what kind of specialist they are treated by, patients can receive drastically different prescriptions for pain related to a condition or following a procedure.
Lo said that any group issuing guidelines should follow up with patients over time to make sure their pain was sufficiently addressed and that their quality of life was not hurt. Too often, he said, providers track only how a policy affects prescribing amounts.
Although opioid prescribing has been trending down since 2012, the report found signs that overprescribing persists. After a surgery, between 41% and 72% of patients don’t finish their prescriptions, according to the report, and between 6% and 14% of patients remain on opioids six to 12 months after an initial prescription following a surgery or emergency department visit. If the underlying issue is addressed, acute pain should not last that long.
Some of the guidelines issued by states have also been difficult to interpret, Lo said, outlining the number of days an initial prescription can last without considering the specifics of a dose or a particular opioid medication.
The 15-member committee defined acute pain as sudden and lasting up to 90 days. Guidelines for acute pain are distinct from the debate about if and how to reduce opioid prescriptions for people with chronic pain, who may have been on the drugs for years.
Prescribing guidelines are meant to strike a balance so that doctors can properly treat their patients’ pain while reducing the chance that people take overly strong doses for too long — which can lead to addiction and overdose — and minimize the number of leftover pills stashed in medicine cabinets, which can be misused by friends or family members.