National Association of Attorney Generals to U.S. Department of Health and Human Services Says to keep CDC 90 MME Limit

There is no slow down to legislators, governors, politicians just on a freight train to ending pain relief for the elderly, sick and helpless. It amounts to state sponsored torture what they are doing and planning.
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National Association of Attorney Generals to U.S. Department of Health and Human Services Says to keep CDC 90 MME Limit

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  • National Association of Attorney Generals to U.S. Department of Health and Human Services Says to keep CDC 90 MME Limit
April 1st 2019

We, the undersigned Attorneys General, write to express our concerns with
the Pain Management Best Practices Inter-Agency Task Force Draft Report
(Draft Report). For many years, state attorneys general have been fighting the
opioid crisis on numerous fronts, from protecting consumers against deceptive
marketing of prescription opioids to closing pill mills. While this crisis
continues, it is incomprehensible that officials would consider moving away
from key components of the CDC Guideline for Prescribing Opioids for
Chronic Pain – United States, 2016 (CDC Guideline). The well-established
risks associated with higher doses of opioids, prescriptions of longer duration,
and concurrent prescriptions of opioids and benzodiazepines demand
reasonable guidelines to inform appropriate decision-making.

Section 4 of the Draft Report proposes to rely solely on the judgment of
providers regarding the dose and duration of opioid treatment. With annual
overdose deaths in the tens of thousands, evidence-based recommendations,
such as documentation and consultation, are necessary. Without reasonable
dispute, widespread opioid prescribing causes immense harm.

In Washington, the Agency Medical Directors’ Group developed an evidence
based guideline that balances individual patient needs with the undeniable
risks of high-dose opioids. Prior to prescribing high-dose opioids, providers
are required to obtain a consultation from a trained pain specialist who agrees
that a high dose is indicated and appropriate. In addition, providers must
routinely monitor and document sustained improvement in function and
quality of life and an absence of defined risk factors that increase risk for
opioid use disorder and overdose. In contrast, the Draft Report emphasizes
frequent monitoring of analgesic effectiveness, relegating function and quality
of life measures to optional considerations.

The Draft Report should be revised to clearly state that there is no completely
safe opioid dose, and that higher doses are particularly – and predictably –

risky. As noted in the Washington State Agency Medical Directors’ Group Interagency
Guideline on Prescribing Opioids for Pain, even with acute low dose opioids (1 – 36 mg/day
morphine equivalent dose or MED), patients are at increased risk for developing opioid use
disorder (OUD).i The likelihood of developing OUD ranges from a 3-fold increase for acute low
dose opioids, to a 122-fold increase for chronic high dose opioids (≥ 120mg/day MED)
compared to patients who are not prescribed opioids.

ii Overdose risk approximately doubles at doses between 20 and 49 mg/day MED, and
increases nine-fold at doses of 100 mg/day MED or more.iii Yet no dose is safe, as studies
in Washington’s workers’ compensation and Medicaid programs have shown that nearly
half of all overdose hospitalizations occur in patients who are on intermittent or lower dose opioids.

Similarly, the Draft Report states that duration of opioid treatment for acute pain, including
trauma and surgery, is best determined by providers without the need for guidelines to inform
appropriate decision-making. Instead, the Draft Report should point providers to surgical
guidelines issued since the CDC Guideline was published. For example, University of Michigan
researchers have developed and made publicly available opioid prescribing recommendations for
25 common Implementing these guidelines has led to 35% to 66% reductions in
opioid prescribing for several procedures with no impact on patients' pain, or their likelihood of
requesting a refill.vii,viii In Washington, the Bree Collaborative and the Agency Medical
Directors’ Group developed a post-operative prescribing guideline informed by more than 200
studies that have been published just in the past several years.ix
The Draft Report also fails to acknowledge that longer duration prescriptions increase patients’
risk for misuse and instead identifies patient characteristics as the drivers of misuse. A study of a
million opioid-naïve surgical patients found that each additional week of opioid treatment was
associated with a 20% increased risk for opioid misuse. A refill increased their total risk by
44%.x Even shorter duration opioid prescriptions can increase risk for misuse, particularly for
youth. For example, most dentists prescribe a median of 20 opioid pills for a tooth extraction

xi, many of which are left unused and available for misuse. Research has found that 16 to 25-yearolds
who receive an opioid prescription for dental procedures are 14.5 times more likely than
other youth to receive an opioid abuse diagnosis within a year.xii Youth continue to face this risk,
even though many studies have demonstrated that non-opioid analgesics are comparable or more
effective for managing dental pain than opioids.xiii,xiv,xv
Rather than reiterating the importance of
limiting exposure to opioids as much as possible, the Draft Report makes the baseless claim that
opioids only have addictive properties in certain at-risk populations. While certain factors place
individuals at higher risk for adverse events associated with opioid use, anyone can become
dependent and misuse opioids, particularly if they are exposed to more opioids than necessary.
Moving away from the CDC Guideline at this critical time would undermine ongoing legislative
initiatives, as well as refinements to standards of medical care. For example, the Montana
Department of Justice is currently spearheading a bill through the Legislature that would bolster
Montana’s Prescription Drug Monitoring Program and limit opioid and benzodiazepine
prescriptions to seven days. This policy change, like others throughout the country, relies on the
CDC Guideline and has the broad support of the medical community, including the Montana
Medical Association, Montana Hospital Association, and the Montana Pharmacy Association. As
a number of studies have demonstrated, while most surgical patients use a fraction of their 3
prescriptions xvi, fully 5% of adolescent patients become chronic opioids users. xvii As Attorneys
General of states with high rates of prescription drug abuse among our youth, policy makers and
prescribers must be encouraged to continue to pursue laws and practices that reduce the high
volume of opioids in our communities.

Finally, the Draft Report must be revised regarding co-prescribing of opioids and
benzodiazepines. According to the National Institute on Drug Abuse, more than 30 percent of
overdoses involving opioids also involve benzodiazepines. The overdose death rate among
patients receiving both types of medications is up to 10 times higher than among those only
receiving opioids.xviii The CDC Guideline appropriately warns against co-prescribing, yet does
not prohibit it outright. Instead, providers are advised to offer naloxone, re-evaluate patients
more frequently, and refer patients to pain and/or behavioral health specialists.
The Draft Report provides no justification for moving away from the CDC recommendation that
clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.
If the Draft Report aims to bring new research to providers’ attention, it should point out that
concurrent opioid and benzodiazepine prescriptions are already all too common – and providers
may not even be aware the extent to which their own patient panel is affected. Recent research
found that more than a quarter of Medicare patients prescribed opioids also fill prescriptions for
benzodiazepines.xix This study found the risk of concurrent opioid and benzodiazepine use rose
with the number of clinicians prescribing medications to the same patient, pointing to the need
for increased communication between providers and reinforcing the value of Prescription Drug
Monitoring Programs.

Since the CDC Guideline was issued, the evidence has continued to mount that opioids achieve
limited pain relief for chronic noncancer painxx and are often no better than other options for
treating acute pain.xxi As attorneys general we have witnessed the devastating effect of unfettered
opioid manufacturing, distribution and prescribing on our public health, social services and
criminal justice systems. The well-established risks associated with higher doses of opioids,
prescriptions of longer duration, and concurrent prescriptions of opioids and benzodiazepines
demand continued constraints. As a matter of public safety, there is simply no justification to
move away from the CDC Guideline to encourage more liberal use of an ineffective treatment
that causes nearly 50,000 deaths annually. ... sg67J9qII
or ... 8-0027.pdf

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