The Medical Board of California has unveiled long-anticipated revisions to its opioid prescribing guidelines, aiming to streamline patient access to necessary care while upholding necessary precautions. A significant clarification from the board emphasizes that these guidelines are not intended to replace a physician's clinical judgment and personalized, patient-focused decision-making.
These new guidelines closely align with recommendations put forth by the California Medical Association (CMA), which urged the board's Opioid Prescribing Task Force to prioritize a balance between prudent risk assessment and ensuring individualized patient care in their efforts to update the guidelines.
In a communication directed to the task force, the CMA underscored the previous guidelines' intense focus on curbing opioid prescriptions to counter opioid-related overdoses. Remarkably, California already maintained one of the lowest opioid prescription rates in the nation when the initial guidelines were introduced, and the state's efforts to decrease prescription rates have persisted. The current surge in overdose deaths, however, is attributed to the illicit use of drugs.
Dr. Sean Mackey, M.D., Ph.D., head of the Stanford University Division of Pain Medicine, served as a senior advisor to the medical board's task force and has endorsed the refined guidelines. In a letter read during the May board meeting, Dr. Mackey, a physician-scientist who tends to patients with chronic and intractable pain, explained, "Our motivation for revising this document was to learn from past lessons and enhance its effectiveness. We acknowledge the necessity of ensuring patient access to safe and efficient pain management while also supporting physicians who treat individuals with chronic pain."
The suggestions from the CMA were broadly incorporated into the guidelines, including the acknowledgment that the medical board's Prescription Reviewer Program (previously known as the "Death Certificate Project") contributed to physicians becoming less inclined to treat chronic pain patients.
The CMA emphasized the importance of nuanced pain treatment in its communication, stating, "It is imperative for the guidelines to recognize the intricacies inherent in pain management and to acknowledge the multifaceted challenges of treating these patients. This encompasses systemic obstacles that hinder patient access to nonopioid therapies or pain specialists, as well as the racial and ethnic disparities present in healthcare."
The updated guidelines address many concerns outlined by the CMA and adopt the association's recommendations, including:
- Reiterating the personalized nature of patient care and clarifying that the guidelines are not intended to be rigidly applied by healthcare entities. Furthermore, they are not intended as legal statutes, regulations, or policies dictating clinical practice.
- Clarifying that patients need not sequentially "fail" nonpharmacologic and nonopioid pharmacologic therapies before considering opioid therapy. The guidelines now stress that the decision to initiate opioids should be based on a careful weighing of anticipated benefits against therapy risks, rather than a requirement for patients to undergo multiple ineffective therapies.
Responding to the CMA's push, the guidelines eliminate morphine milligram equivalent (MME) thresholds. The 2016 Centers for Disease Control and Prevention guidelines had introduced a uniform approach to opioid therapy, but it was criticized for its detrimental impact on patient care. The new guidelines provide a nuanced examination of MME usage, highlighting the necessity of personalized, patient-centered care, and thorough medical recordkeeping to document prescription decisions. Notably, the final version no longer includes the initially proposed upper limit of 90 MMEs for opioid prescriptions.