When Opioid Prescribing Guidelines Become Rules
Clinicians should familiarize themselves with their state’s medical commission’s guidance on opioid prescribing.
Physician assistants (PAs) and nurse practitioners (NPs) who prescribe opioids and other pain medications understand the stress and anxiety that is associated with the willingness to do what many prescribers won't. As more providers opt out of using opioids to treat patient's pain, those who do prescribe these medications feel a greater sense of pressure to prescribe them correctly.
One of the challenges that clinicians practicing in this field face is determining which pain prescribing guideline to follow. Examples of these include state-issued guidelines, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain issued in 2016, and the Federation of State Medical Boards Guidelines for the Chronic Use of Opioid Analgesics updated in 2017.
Wading through the various rules and guidelines on prescribing opioids can be overwhelming. Part of the challenge is that when an agency like the CDC releases guidelines, they will often try to reassure providers by noting that “these are just guidelines, they are not rules.” But what often happens after a high-profile agency creates guidelines is that they appear in state commissions as rules. And as a member of my state's medical commission, I know that not knowing the rules can carry high stakes, including the risk of discipline from state boards.
So, what's a clinician to do? I recommend taking the time to keep up with your state commission and what practices they are pursuing. This is not as difficult as feared as most commissions are eager to provide information about their state's pain and prescribing rules. Another valuable step may be to stay engaged with state medical associations, as they often create resources with frequently asked questions in order to promote awareness of state regulations.
It all can certainly feel a bit overwhelming; however, there are resources available that can help simplify the concern of staying out of trouble with the state medical board. It is true that opioid prescribing has a time and a place, and it is also true that special care needs to be taken when prescribing high-risk drugs. But there are ways to wade through it. One resource that I find valuable is the State of Washington's Agency Medical Director's Group (AMDG), which in addition to presenting opioid-prescribing guidance provides interagency guidelines for evaluating health technologies, including devices, durable medical equipment, procedures, diagnostics, and off-label drug use. The most recent version was published in 2015, and it's a rich document with many helpful resources and evidence-based guidance.
Whatever resource you use, try to keep it simple and treat pain prescribing the same way you would approach other types of prescribing. If you feel like you're sometimes “winging it” with pain prescribing, identify that as a red flag and make sure that you are up to date on the latest medications, prescribing guidelines, and state rules. Doing so does not have to take an inordinate amount of time and energy; it just needs to be part of a prescribing clinician's systematic approach to safe and effective prescribing for all illnesses and conditions.