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National opioid group addresses challenge of addiction and pain management

Stanford anesthesiologist Edward Mariano discusses the progress and goals of the National Academy of Medicine's opioid collaborative.

When Stanford anesthesiologist Edward Mariano, MD, joined the National Academy of Medicine's Action Collaborative to Combat the U.S. Opioid Epidemic last year, he and his colleagues began examining the available guidelines limiting how doctors should prescribe the drugs.

But after reviewing the various rules and restrictions from medical subspecialties and state legislatures that govern how many pills doctors are allowed to prescribe and for how many days, the prescribing guidelines working group came to a conclusion: To best help patients who are suffering from pain or addiction, doctors don't need more rules.

They need more options.

"Just addressing opioid prescribing by itself is extremely diverse. How do you treat a patient who is opioid naive and has his or her first surgical procedure... versus a patient who's been on opioids for years for chronic low back pain... versus an acute or chronic painful condition in a patient who has a substance use disorder?" Mariano told Scope. "There is no one guideline by any one organization that will ever be sufficient."

After working in private for several months, the collaborative had its first public meeting in Washington, D.C. last week. Mariano, a professor of anesthesiology, perioperative and pain medicine, is a member of the prescribing guidelines and evidence standards working group as well as the research, data and metrics working group. He spoke with me about the progress so far.

Founded in 2018 as a public-private partnership, the two-year collaborative includes more than 125 organizations across the U.S. -- ranging from government agencies, community organizations, hospital and medical systems to academic institutions, nonprofits and health professional societies. They have joined forces in hopes of reversing or curbing the trends in opioid misuse and abuse. Ultimately, the final recommendations will be disseminated to health care professionals, educators, policymakers, insurance companies, patients and caregivers around the country.

Over the next several months, the prescribing subgroup aims to produce evidence-based recommendations for pain management in different situations. The treatments will include non-opioid medications, non-pharmacologic interventions such as physical therapy, hypnosis and acupuncture, and other pain-relief tactics -- including opioids.

"If we treat pain better, with all the options available to us, then patients will not have to rely on opioids as their only method of managing pain," Mariano said.

The prescribing working group will address questions such as:

  • Which patients would benefit from acupuncture or cognitive/behavioral therapy?
  • How should you treat a patient who's been on opioids for years for chronic pain? What about patients with substance use disorders?
  • Under what circumstances are opioids actually indicated?
  • What are the safest ways to help patients taper off opioids?

The working group will host a public webinar on tapering this summer and expects to come out with a paper proposing recommendations at the end of this year after seeking feedback from physicians, patients and patient advocacy groups, Mariano said. The full collaborative will hold its next public session this fall.

Photo by D. Robert Wolcheck

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