stantiate the concern that changes in opioid prescribing practices may lead to unintended increases in the use of heroin or illicitly obtained opioids. Provider and Patient Perspective: Faced with the dilemma of trying to address the increase in prescription opioid related deaths in a setting of little to no high quality data, the authors review provider and patient perceptions about opioid therapy for CNCP. Providers are worried, frustrated, and lack confidence in addressing concerns about opioid risk with their patients. In turn, patients are concerned about “addiction,” report high levels of side effects, and are unsure about the overall benefit of opioid therapy when there is little else available to treat their symptoms. Cost: The authors point to the high direct and indirect costs of prescription opioids including prescription expenses; costs of opioid-related overdose; and costs related to abuse, dependence, and misuse compared with costs of non-pharmacologic and non-opioid based pharmacologic therapies.

RECOMMENDATIONS When it comes to distilling the evidence into recommendations for clinical practice, here, too, the authors feel that the crisis regarding prescription opioid related deaths outweighs the lack of compelling, gold-standard level evidence.

HERE IS MY TAKE ON THE EXTENSIVE RECOMMENDATIONS: Providers should have a systematic approach to opioid prescribing: proceeding with caution; identifying a clear and compelling indication to prescribe opioids; and being frank with patients about what we know about the risks and benefits of these treatments. After all, they are worried about the risks of opioids as well. When providers choose opioids, they should be used at the lowest effective dose. While the guidelines stop short of naming a dose ceiling, the increase in overdose risk at ≥ 50 MME/day is repeatedly mentioned. Furthermore, the recommendation is to avoid increasing dosage ≥ 90 MME/day without clear and compelling justification. IR opioids are favored over ER/LA formulations at the start of therapy. Methadone and transdermal fentanyl should not be first line choices. The guidelines raise questions about the use of both ER/LA formulations along with as-needed IR dosing for so called “breakthrough pain.” For those patients already at high doses, the recommendation is to review the evidence of increased risk and discuss tapering to a safer dose. When tapering, go slow, about 10% per week, and allow for pauses in the taper if patients are experiencing withdrawal symptoms. Tapers may be accelerated if there is very high risk for overdose. Tapers are not necessary if there is compelling evidence of total diversion. Opioids should be used as part of a multimodal treatment strategy that includes evidence-based non-pharmacologic and nonopioid medications. Clear goals should be established at the outset for assessing risk and benefit of ongoing treatment, along with an “exit strategy” if risk outweighs benefit or if there is no benefit. As risk of opioid misuse or overdose is hard to predict, providers should take a “universal precautions” approach to monitoring and mitigation strategies that involve frequent and regular followup. Here the guidelines recommend follow-up within the first four weeks of start of therapy and at least every three months thereafter. In addition, the guidelines recommend checking the PDMP before the start of therapy and at least every three months thereafter. UDT 20 | THE BULLETIN | MAY / JUNE 2016

should be obtained before the initiation of therapy and at least annually thereafter. One final mitigation approach is the risk based co-prescribing of naloxone (e.g., history of overdose, history of substance use disorder, high opioid dosage (≥50 MME/day), concurrent benzodiazepine use, which should be avoided whenever possible). When treating acute pain, the recommendation is limit opioids to three days or less, and not more than seven days in rare circumstances. If during the course of therapy, opioid use disorder is diagnosed, providers should offer or arrange for patients to access medication-assisted treatment with buprenorphine or methadone.

COMMENTARY Depending on one’s clinical setting, these guidelines may align to varying degrees with already established standards. More likely, though, is that current clinician practice varies greatly from these guidelines. As such, greater provider and patient education, awareness, and technical assistance may be needed to successfully transform the use of opioid therapy in CNCP treatment. As overwhelming as continuing to treat CNCP has been as a medical community, changing practice may feel more overwhelming. This will take time. After all, it took us almost 20 years to come to this point. Whatever you may think of the strength of the arguments for change in opioid prescribing practice, it is clear that change is here. In closing, I offer these thoughts and calls to action as a way to guide our way forward in a process that will overhaul the way we treat CNCP in the years to come—hopefully to the benefit of our patients and communities: • We want to advocate for payors and other stakeholders to support the creation of payment models to support evidence-based non-pharmacologic therapies. • When we make a change in our practice, we want to be transparent with our patients about why we are making the recommendations we’re making. • We want to reach out to our colleagues within our practices; acute, specialty and tertiary care settings; and other community stakeholders to craft a consistent, compassionate, and comprehensive approach to pain management that focuses on safety and well-being. • We don’t want to refuse to write another opioid prescription. Despite the risks, there are still compelling indications for the use of opioids in treating CNCP. • We don’t want to make sudden changes in the treatment plan that leave patients feeling judged, blamed, abandoned, or mistrusted. After all, they didn’t create this problem. We need their trust and they need to know our commitment is steadfast in order for us to back out of this crisis together with the least harm possible.

REFERENCE Dowell, D.; Haegerich, T.; Chou, R “CDC Guideline for Prescribing Opioids for Chronic Pain –United States, 2016:” MMWR 65(1):1-49

Joseph Pace, MD, is San Francisco Health Network Director of Primary Care Homeless Services and Medical Director, Tom Waddell Urban Health. He is co-chair of the San Francisco Safety Net Pain Management Work Group. He also co-hosts City Visions, a “thinking person’s talk show” on KALW-FM public radio.