American Academy of Physical Medicine and Rehabilitation Position Statement on Opioid Prescribing

The American Academy of Physical Medicine and Rehabilitation (AAPM&R) is the national medical organization representing more than 10,000 physicians who are specialists in physical medicine and rehabilitation (PM&R). PM&R physicians, also known as physiatrists, treat a wide variety of medical conditions affecting the brain, spinal cord, nerves, bones, joints, ligaments, muscles, and tendons. PM&R physicians evaluate and treat injuries, illnesses, and disabilities and are experts in designing comprehensive, patient-centered treatment plans. Physiatrists use cutting-edge as well as time-tested treatments to maximize function and quality of life. The AAPM&R recognizes that the current opioid epidemic is one of the most devastating public health threats to our society. With 2 of 3 drug overdose deaths involving an opioid in 2016, we are concerned about the risk that opioids pose to the individual patient and the public at large when not used appropriately 1. In addition, our specialty recognizes that chronic pain is the cause of suffering for more than 100 million Americans 2. It is our goal to avoid adverse events associated with opioid usage, including addiction, misuse, abuse, diversion, and death. Our specialty is striving to mitigate overprescribing and to reduce stigma as well as the undertreatment of chronic pain. Many physiatrists are leaders of health care teams that provide essential care for patients presenting with both acute and long-term pain management needs. The physiatrist's goal is to improve patient quality of life by developing a treatment plan that minimizes pain and maximizes daily functioning. Compelling scientific evidence shows that physical therapy, behavioral health, nonopioid medications, and interventional procedures may be better treatment options compared with opioids alone 3. We strongly advocate for improvement in access to multimodal treatments for pain. It is vital that payers review their policies to increase the availability of evidence-based, multimodal, nonopioid pain management treatments. Although physiatrists aim to provide interdisciplinary, nonpharmacologic regimens, their treatment plans also may include the judicious use of opioid medications. AAPM&R supports access to chronic opioid therapy for terminally ill patients, such as those with cancer or undergoing end-of-life care. Although there is limited evidence-based science to support the use of opioids for chronic, noncancer pain, carefully selected patients demonstrate functional improvements from a treatment plan that includes opioid medications. As such, it is important to preserve access to these medications for patients with moderate-to-severe chronic pain. Well-founded concerns related to opioid usage must be balanced by our commitment to treat our patients as individuals, using the best medical evidence and the highest degree of compassion possible. Physiatrists are committed to effectively managing the complex clinical, functional, and psychosocial issues associated with chronic pain management. The primary goal of pain management is functional improvement and restoration. The physiatric philosophy is to first approach a patient's functional status and design a means of achieving functional goals rather than to first approach a patient's symptomatology when treating chronic pain. Incorporating patients in a shared decision-making process that explores all appropriate treatment options and results in clearly defined functional goals and improved quality of life should precede a prescription for an opioid drug. Functional status should be assessed and monitored with documentation of functional improvement to validate continuation of chronic opioid therapy. Acute, subacute, and chronic pain management should be multimodal. AAPM&R believes that evidence-based, pain management treatments should include cognitive behavioral therapy, integrative treatments (ie, mindfulness, acupuncture), nonopioid medications, physical therapy modalities, interventional procedures, and appropriate opioid medications when indicated 3. Furthermore, the use of opioids should be in coordination with appropriate exercise programs, behavioral health treatment options, and interventional procedures. AAPM&R will continue to advocate for patient access to comprehensive multimodal, and multidisciplinary therapies for pain management. Opioid dosages should be the lowest necessary to achieve functional improvement. Physiatrists recognize that pain is a subjective and personal experience that widely varies by patient and condition. It is important to treat all patients individually and use the opioid dosage appropriate for the particular pain syndrome. Standardized criteria of mild, moderate, and severe pain are not appropriate categorization, as all individuals experience pain uniquely, and a specific plan for each patient should be formulated. Moreover, although dosing above the Center for Disease Control and Prevention's recommendations 3 should be considered on an individual basis, limiting the days of medication or the maximum morphine equivalent dose for chronic pain is not appropriate. Physiatrists treating patients with acute and chronic pain should continually assess both levels of pain and function to evaluate the feasibility of decreasing or discontinuing an opioid. Chronic opioid therapy should be accompanied by appropriate risk stratification and ongoing risk management. From the start of care, physiatrists should educate the patient to understand the clinical pathologic process; all potential treatment options including the patient's individual risks, benefits, and alternatives; and most importantly understand that the goal is to restore function by minimizing pain. Appropriate risk management also includes signed opioid agreements, regular urine drug screening, and regular checks of the state prescription monitoring databases. The patient's initial risk abuse should be screened by a validated scale, and patients should be screened throughout their therapy. Opioid therapy for new onset of acute pain should be restricted. Due to evidence that acute pain treated with opioids can lead to opioid dependence within a short time period, we support restricting opioid prescriptions for acute pain, including postoperative pain, generally to less than or equal to 14 days with regular reassessment, based on severity of the pain 3-5. We encourage the use of nonopioid analgesics in this setting, including in combination with opioids when appropriate. Every physiatrist who prescribes opioids maintains a commitment to patient safety and continuing education. AAPM&R has long encouraged our members and their health care teams to continually advance their knowledge regarding pain management and proper opioid prescribing. We believe that physician education for the safe use of opioid analgesics continues to be one of the most effective means of decreasing the risk of morbidity and mortality associated with the use of opioid drugs. Our specialty is committed to ensuring patient safety, and our Academy supports member efforts to understand and implement best practices for pain management. AAPM&R recognizes that both the opioid epidemic and acute and chronic pain management are difficult and complex issues. We are committed to advocating within our specialty for the adoption of best practices related to pain management and opioid prescribing. AAPM&R continues to collaborate with various other medical specialties to provide a unified voice on this critical issue to make tangible, impactful changes to enhance physician education and increase safety for patients and the public. This AAPM&R Position Statement is intended to provide general information to physiatrists and is designed to complement advocacy efforts with payers and policymakers at the federal, state, and regional levels. The statement should never be relied on as a substitute for proper assessment with respect to the specific circumstances of each case a physiatrist encounters and the needs of each patient. This AAPM&R statement has been prepared with regard to the information available at the time of its publication. Each physiatrist must have access to timely relevant information, research, or other material that may have been published or become available subsequently. In the Fall of 2017, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) Board of Governors approved formation of the Pain Management and Opioid Task Force (Task Force), a coordination between the Academy's Quality, Practice, Policy and Research (QPPR) Committee, the Medical Education Committee (MEC), and the Pain Council. This joint QPPR-MEC Task Force was charged with composing a comprehensive response to the physiatrist's role in pain management and controlling opioid prescribing, including crafting an updated position statement and enhanced educational initiatives. The Task Force convened in early 2018 and worked to reach consensus on their top opioid prescribing concerns and make significant revisions to the 2014 AAPM&R position statement on Opioid Prescribing. The QPPR Committee provided guidance on the draft statement and, with the Task Force, jointly submitted it for Board review. The Board of Governors approved the Position Statement on Opioid Prescribing in April 2018. This document did not undergo standard Journal peer review. Members of the Pain Management and Opioid Task Force and authors of the 2018 Opioid Prescribing Position Statement are Erik Shaw, DO, Chair, Diane W. Braza, MD, David S. Cheng, MD, Erik Ensrud, MD, Andrew S. Friedman, MD, Rita Hamilton, DO, Jason Miller, MD, Ameet Nagpal, MD, Saloni Sharma, MD