The Medical Board of California recently published a long-awaited update to its opioid prescribing guidelines, which will make it easier for patients to get the care they need while maintaining appropriate safeguards. Importantly, the medical board has clarified that the guidelines are not intended to replace a physician’s clinical judgment and individualized, patient-centered decision-making.

The guidelines are consistent with recommendations from the California Medical Association (CMA), which had urged the medical board’s Opioid Prescribing Task Force  “to use balancing between appropriate risk assessment and ensuring that patients receive individualized care as the guiding principle as you work on this latest update of the guidelines.”

In a letter to the taskforce, CMA noted that previous prescribing guidelines were acutely focused on reducing opioid prescribing to address opioid-related overdose. California already had one of the lowest opioid prescribing rates in the country when the previous guidelines were passed, and has continued to reduce prescribing. The current surge in overdose deaths is related to use of illicit drugs.

The chief of the Stanford University Division of Pain Medicine Sean Mackey, M.D., Ph.D., served as a senior advisor for the medical board’s taskforce and endorsed the revised guidelines.

“I’m a physician scientist, I care for people suffering from chronic pain, many who have intractable pain. Our motivation for revising this document was to learn from the lessons in the past and make it better,” Dr. Mackey said in a letter read at the May board meeting. “We recognize the need to ensure patient access to safe and effective pain management treatment, and at the same time, the need to support physicians providing treatment for people with chronic pain."

CMA’s requested changes were largely incorporated into the guidelines, including a recognition that the medical board’s Prescription Reviewer Program (formerly known as the “Death Certificate Project”) contributed to physicians being less willing to treat patients with chronic pain.

“We think it is critical to ensure that guidelines recognize the nuance that treating pain requires and acknowledge the complex realities of treating these patients, which include systemic barriers for many patients to access nonopioid therapies or pain specialists and racial and ethnic disparities in care,” CMA wrote in the letter.

The new guidelines address many of CMA’s concerns and adopted CMA recommendations, including:

• Reinforcing the individualized nature of patient care and making clear that it is not intended to be applied as an inflexible standard by health care entities and is not a law, regulation and/or policy that dictates clinical practice.
• Clarifying that patients should not be required to sequentially “fail” nonpharmacologic and nonopioid pharmacologic therapy before proceeding to opioid therapy.  The guidelines now state that the basis for initiating opioids should be whether the benefits are anticipated to outweigh the risks of the therapy, rather than by patients having attempted multiple therapies that have inadequately addressed their pain.     

CMA also advocated for removing morphine milligram equivalent (MME) thresholds, because those included in the 2016 Centers for Disease Control and Prevention guidelines “established a ‘one-size-fits-all’ approach to opioid therapy that harmed patients” and perpetuated “the false idea that MME thresholds improve patient care.” The adopted guidelines provide a nuanced analysis of using MME, stressing the need for care being individualized and patient centered and for adequate medical recordkeeping that documents prescribing decisions. The final version removed originally proposed language that suggested an upper limit on opioid prescribing of 90 MMEs.