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Guidelines on opioid weaning address legacy patients


Three years after issuing strict guidelines on opioid prescribing that were well-adopted in the workers compensation sector, the U.S. government has issued a new guide for helping patients on long-term opioid prescriptions reduce their medications if possible — a much-needed clarification that will help the industry grapple with the ongoing issue of legacy claims, experts say.

“We always have this problem with the pendulum swinging too far the other way,” said Dr. Steven Feinberg, a pain expert and founder of the Palo Alto, California-based Feinberg Medical Group, of the previous guidelines that he believed were too strict with opioid prescribing for chronic pain patients. He called the new guidelines “good medical common sense.”

The new guidelines, issued by the U.S. Department of Health and Human Services on Oct. 10, are meant to give doctors a better grip on tapering of opioids, do not call for eliminating them from a patient’s care when “the benefit of using opioids outweighs the risk,” and provide “advice to clinicians who are contemplating or initiating a change in opioid dosage.”

The guidelines call for “care” and “a patient-centered experience,” according to a statement issued by the department.

“We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, a doctor and assistant secretary for health at HHS, in the statement. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”

Comp industry experts, meanwhile, view the move as an about-face on guidelines issued by the Centers for Disease Control and Prevention in 2016 that called for reductions in prescribing and have “hurt” chronic pain patients by greatly reducing medications, said Dr. David Deitz, a medical/workers compensation consultant who runs his own consulting firm David Deitz & Associates LLC out of Westport, Massachusetts.

“The original chronic pain guideline in 2016 has been misinterpreted by various folks,” he said of the CDC’s guidelines issued in 2016 that declared opioids not effective in managing chronic pain. “The new guidelines provide more of a scientific guidance for … people who are involved in overseeing the care of chronic pain patients who are interested in what is the appropriate management for weaning these patients” off opioids.

“What has been seen across both health insurance and workers compensation is a subset of payers and managed care group and medical practices (that) have interpreted the guidelines as, ‘if we have patents with a lot of opioids we have to get them off (the medication),’” said Dr. Deitz. “The latest guidelines are trying to say, ‘weaning is a really good thing but not everybody can be weaned and not everybody should be weaned.’ And when you (wean) you have to take a whole bunch of things into consideration. Are you going to create different problems for them if you wean them?”

The older guidelines created “misunderstanding” in the medical field, according to Reema Hammoud, Southfield, Michigan-based director of clinical pharmacy Sedgwick Claims Management Services Inc.

“People were using those (CDC) guidelines on the legacy claims,” she said, referring to older workers compensation claims where opioids were prescribed long before the CDC aimed to tackle the growing concern of too many opioid prescriptions.

Most in the comp industry, however, caught on that tapering off drugs slowly was necessary, according to Ms. Hammoud. Yet the new guidelines better arm the workers comp system in the management of such claims, she said. “These new guidelines … gives us a better pathway to help the patient manage their pain and have a better tapering that is safer for the injured worker.”

Opioid weaning “has to be carefully done,” said Michael Coupland, West Palm Beach, Florida-based network medical director for IMCS Group Inc., a national network of clinicians working in the comp sector, and an advocate for better medical management for patients who take opioids.

According to Mr. Coupland, a large issue has been seeing all opioid patients through the same lens.

“The experience we have is you look at those who are truly addicted (and) you are going to go down one pathway with them,” he said, adding that such assessments are “usually based on previous addiction such as alcohol or other drugs.”

“And then the other group who got on long-term opioids because of a pain condition and you can start weaning them (but) you want to help get off of them in a way that doesn’t exacerbate their pain,” said Mr. Coupland, adding that a too-fast approach can cause major health issues. An example he gave at a presentation on opioid weaning in 2018 is that a person with a heart condition may suffer a heart attack while weaning.

“The going-slow approach is more appropriate,” said Mr. Coupland.



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