So, CDC… What's Next?

I had the opportunity to attend the CDC's National Center for Injury Prevention and Control (NCIPC) meeting of their Board of Scientific Counselors (BSC) in Atlanta on June 19. The room was filled with highly educated, experienced and passionate people representing a variety of specialties: educator, physician, psychiatry, psychology, physical therapy, policymaker, scientist, epidemiology, pharmacist. The agenda was about studying the progress made with the #opioid epidemic since the publishing of the CDC Guideline for Prescribing Opioids for Chronic Pain in April 2016. The stated goal was to discuss how best to answer questions like "What would the opioid prescribing rate be in the United States if best practices were followed?" and "How much should prescribing change to bring prescribing rates in line with best practices?"

I added another question during my two minute public comment ...

So if everyone knows the dangers of opioids now, what's next?

What I proposed as the answer was the #BioPsychoSocialSpiritual treatment model that opens opportunity for non-opioid and non-pharma treatments. That includes other prescription drugs and maybe even medical cannabis. It also includes yoga, Tai Chi, mindfulness, weight loss, CBT, better nutrition and anti-inflammatory diet, more sleep, an active lifestyle, physical therapy, acupuncture, dry needling, mindfulness, chiropractic, deep diaphragmatic breathing, and more. Coping mechanisms, resilience and engagement. The true definition of pain management, where it is not out-sourced to something or somebody else but in-sourced by the individual. While non-opioid treatments are not included in the scope of this workgroup, this new study is a natural extension of the guidelines and a conversation starter about "what's next" (including the best use of opioids).

They got it.

The good news is the proposed workgroup was unanimously approved after the day-long discussion. They have a tight timeframe to complete their work - November/December of this year. And they have a lot of work to do. But I have confidence they will accomplish their goals.

Following are the comments that most resonated with me:

• The NCIPC has three current priorities: opioid overdose, suicide and adverse childhood experiences (ACE) prevention. In their opinion, all three are preventable. Also in their opinion, all three are interrelated. Absolutely.
• They understand fully the three "waves" of the opioid epidemic: In 1999 the over-prescribing of methadone and Rx opioids; In 2010 the resurgence in heroin; in 2013 the introduction of synthetic opioids like fentanyl. They understand that most deaths now are not from prescribed opioids. Their concern is what might be in the fourth wave.
• Non-pharma treatment options need to be more readily available to enhance chronic pain management. One member mentioned that #WordsMatter, saying "non-pharma options" implies that "pharma" is the first appropriate option. The suggestion was to find another phrase (maybe "Complementary and Integrative Health").
• The goal of pain management: Listening to patients; Understand their level of pain, decrease in physical function, and changes in quality of life; Identify, communicate and execute the best treatment plan with the most benefits and least risks. Absolutely.
• Communication without fear mongering is incredibly important.
• It is increasingly common for individuals to have multiple overdoses in one year or even shorter timeframe. This is creating compassion fatigue, including repeated "trauma" to first responders. #Sad
• There should be no abrupt discontinuance of opioids. They know that is happening in some cases (unfortunately). Any change in drug regimen should be done with patient consent. They know that is not happening in some cases (unfortunately). All of the stakeholders, but especially everyone associated with the CDC, need to evaluate (and maybe adjust) messaging to ensure it's being properly relayed and is being accepted. And that these two principles are not breached. Absolutely.
• "So many prescribers believe de-prescribing is futile." In fact, during the discussion, it appeared that many in the room felt the same way (or at least didn't fully understand the process). That perspective, by prescribers and policy makers, needs to change so the public knows it's possible (although not guaranteed). I relayed in my comments having seen long-term weaning from dangerous and clinically inappropriate polypharmacy regimens be successful and therefore it is not futile. #CleanUpTheMess is challenging but not impossible.
• There needs to be a focus on individual and community resilience. Current priorities are primarily focused on risk factors (negative). Maybe the focus on policies / practices and message / messenger should be more positive (e.g. how to encourage help-asking / help-receiving, active engagement). That messaging needs to be geared towards convincing people to utilize services and providing information at the right time in the right venue.

And now some details about the workgroup itself:

• The goal of the workgroup: Understand current prescribing practices and how closely they align with best practices, balancing patient safety and patient needs.
• Some of the example questions that could be part of the workgroup's scope: What is an appropriate length of time for opioids for an acute diagnosis or procedure not already defined in the literature; What is an appropriate dosage of opioids for acute diagnosis or procedure; In your clinical experience, what percentage of the time are opioid prescriptions aligned with best practice for chronic diagnosis.
• There have been some discrepancies noted thus far in their initial research: Amount of opioids prescribed vs. the amount actually taken by the patient; Amount of opioids prescribed vs. subjective reports of pain by patients; Marked variation in opioid prescribing practices by clinicians for certain diagnoses or following certain medical procedures (cross-specialty, geography).
• This point was stated repeatedly - This study (output from the workgroup) will notreplace or extend the 2016 opioid guidelines. They will not be new recommendations. They recognized that the 2016 guidelines have been misconstrued as "rules" (mentioning they are much more than just day supply caps) and they want the scope of the workgroup's deliverable to be very clear what it is - and what it isn't.
• The workgroup will use health insurance claims data from Q1 2016 thru Q1 2018 of out-patient opioid prescriptions for acute and chronic pain treatment (with some medical conditions exempted) as the source of their research. Other data source suggestions were the National Hospital Care Survey, Medicare/Medicaid, and Workers' Compensation.
• And that raised an interesting question: Just exactly what are the best practices? There are many treatment guidelines (including in Work Comp) and scientific studies. They don't all agree. There could be some helpful perspectives from international sources (in countries that don't have the same over-prescribing issues as the US). Are best practices how opioids were used prior to the mid-1990s? Should they still incorporate pain as the "fifth vital sign"? Should they take into consideration how society views pain? Would they consider opioids as a “standard of care”? What about other pain management modalities? How would it take into account level of functionality and cultural approaches to pain? A lot of questions to consider when deciding upon THE BEST practice to which current prescribing behavior should be compared. Determining that baseline is the first and most important step.
• The workgroup draft roster included the following specialties: Dentistry, internal medicine / family practice, pediatrics, emergency medicine, surgery, pain management / anesthesiology, OB/GYN, bioethics, oncology/palliative care, hematology, PM&R, neurology, and psychiatry. It also include patient advocatesand the FDA, VA, CMS, and Indian Health Services. During follow-up conversation it was suggested the following be added: Behavioral health, occupational medicine, pharmacist, nursing, PA and NP, social workers, sports medicine, orthopedist, adolescent psychologist, family practice, geriatrics, physical therapist. Then a statement made that everyone seemed to agree with: It would be better to have fewer members per specialty and more specialties included. It's obvious creating the roster of members and advisors will be a large but important task to ensure they draw the broadest and most inclusive conclusions from the data.

They mentioned some helpful resources during the discussion:

• Essentials for Childhood initiative (to address ACE)
• RxAwareness (educational resources currently used by 27 states)
• CDC Injury Center Research priorities (pages 15-17)
• The HEAL (Helping to End Addiction Long-term) initiative
• 5-Point Strategy To Combat the Opioid Crisis from the US Department of Health and Human Services
• The NIOSH Center for Workers' Compensation Studies and Total Worker Health
• The GHSA "Drug Impaired Driving" report

In my opinion, after hearing the dialogue among this diverse group of people for almost eight hours, the CDC understands that pain management is an interdisciplinary, multi-modal, complex, individualized treatment plan that goes well beyond just prescribing an opioid. That was very reassuring to hear.

So, CDC ... What's Next? A broader discussion about how people can manage their pain. That's what.

ABOUT THE AUTHOR 

Mark Pew, SVP of Product Development and Marketing for Preferred Medical, has been focused since 2003 on the intersection of chronic pain and appropriate treatment, ranging from the clinical and financial implications of opioids, benzodiazepines and other prescription painkillers, to the evolution of medical marijuana, to advocacy for the BioPsychoSocialSpiritual treatment model. Educating is his job and passion. Contact Pew here, on LinkedIn at markpew, or on Twitter @RxProfessor.

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