Chronic opioid therapy needs to be individualized, but most people aren’t getting that

In response to the opinion piece Applause for the CDC opioid guideline authors we would like to correct the record. We were surprised to see a reference to work done by the Bree Collaborative as an example of a public program advocating involuntary tapers among patients on chronic opioid therapy for pain; this is incorrect.

The Collaborative has convened a workgroup to develop best practices for opioid prescribing for Washington state since late 2015 and is now focused on developing guidance on a patient-centered approach for people who have been prescribed chronic opioids for pain. We are a public-private partnership that makes recommendations to our state including to state agencies.

{mosads}We agree that pain management and chronic opioid therapy needs to be individualized. But right now most people are not having their needs adequately assessed or met. Many people are not receiving adequate evidence-based treatments such as cognitive behavioral therapy or effective reactivation focused on functional improvement.

Most people are receiving care in primary care, where clinicians do not generally have enough tools at their disposal in the community to address complex pain or opioid issues. Developing a systematic approach to support people with chronic pain and the clinical community is a key goal of the Bree Collaborative.

About five months ago, and partially in regard to the concerns about forced tapers, we undertook a new project focused on patients on chronic opioid therapy for chronic pain. Our approach will be patient-centered and based in the available evidence. Our idea is to start with engaging patients, then do a comprehensive assessment, and determine together with patients and their families or significant others whether to stay on opioids or taper at a rate consistent with their clinical and social situation or to treat opioid use disorder, if present.

As a guide to evidence-based thinking in this field, we are also helping our state agencies to plan a state-of-the-art conference on Aug. 9 in Vancouver, Washington. Topics will include determining which patients may benefit from staying on opioids. It is therefore confusing to us how the author can conclude that the Bree Collaborative has encouraged, or plans to encourage, forced tapering for all patients on chronic opioids.

We are basing our work on the Interagency Guideline on Prescribing Opioids for Pain developed by the Washington State Agency Medical Directors Group and yes, also look to our Federal thought leaders such as the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain. We agree that there is too little research involving outcomes that matter to patients and look forward to the lessons learned from Professor Darnall’s Patient-Centered Outcomes Research Institute (PCORI) trial and other currently funded PCORI studies.

Our opioid prescribing workgroup engages a broad group of clinical and academic experts as well as patients to develop recommendations made by and for our clinical and patient community. Due to the lack of a standard way to measure opioid prescribing we developed strategic prescribing metrics. In response to a lack of guidance for dentists coupled with high rates of adolescent exposure to opioids through wisdom teeth extraction, we developed guidelines for dentists. When we learned of uncertainty in the provider community about how to apply opioid prescribing guidelines to post-surgical pain care, we developed guidelines on opioid prescriptions after surgery. We also have created patient and provider educational materials. All our meetings are open to the public at which public input is always encouraged.

Our Collaborative was created by our Washington state legislature to improve health-care quality, outcomes and affordability for our state. Our governor-appointed members select about five health-care services every year that have a patient safety issue, show variation in clinical practice, or that have high cost and poor outcomes. All members are volunteers. We then convene workgroups made up of clinical and administrative experts, patients, community organizations and other groups to develop our evidence-based recommendations.

We have worked on a wide variety of topics including reducing inappropriate cesarean sections, on increasing the use of shared decision making, and on integrating behavioral health into primary care, among others. We have also developed a set of guidelines for delivering effective collaborative care for chronic pain, the direction we believe all payers should be moving towards. We also believe that everyone should be asked about depression and suicidal ideation and have developed guidance to support these processes.

Virginia Weir MPH, is the director of the Bree Collaborative, serves on the board of the Washington State public health association, and is a clinical instructor at the University of Washington School of Public Health. Gary Franklin M.D., MPH is a Research Professor with the University of Washington, Chair of the Washington Agency Medical Directors Group, Medical Director of the Washington State Department of Labor and Industries, and Co-chair of the Bree Collaborative Opioid Prescribing Workgroup. Andy Saxon, M.D. is a professor with the department of psychiatry and behavioral sciences at the University of Washington; director of the Center of Excellence in Substance Abuse Treatment and Education (CESATE) VA Puget Sound Health Care System, and co-chair of the Bree Collaborative Opioid Prescribing Workgroup.