CDC Guideline for Prescribing Opioids, 2022: Integrating Dosing Benchmarks With Shared Decision-Making (2024)

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August 1, 2023

An Evidentiary Standard for Assessing Policies Affecting Shared Decision-Making in Opioid Therapy

Chad Kollas, MD, FACP, FAAHPM | Orlando Health Cancer Institute

I am disappointed and alarmed that other pain care clinicians have not challenged Sullivan et al on their assertion that “long-term opioid therapy induces a state of opioid dependence that compromises patients’ decisional capacity (1).” The absence of a timely opposing comment to their article could be misinterpreted as meaning that their view on the topic is authoritative. With that in mind, I would remind readers that Sullivan et al have based this claim based solely on a single policy article that explores the limits of shared decision making (SDM), but offers no objective clinical evidence for their assertion (2). In that article, Elwyn et al propose that patients requesting opioid prescriptions should face “severe limits on SDM” because of “the responsibility of clinicians for the safety of the individual or the well-being of the broader population (2),” again without presenting any objective evidence for their position.

Foundational bioethical and medicolegal principles protect the medical autonomy of patients who have an impaired ability to participate in shared medical decision-making (3-5). Relevant analyses of legal reasoning applied in landmark cases within the U.S. judiciary system for defining surrogate medical decision-making establish an evidentiary standard to protect the rights of patients who lack the capacity to participate in discussions about determining their medical care. In those cases, courts have embraced a “clear and convincing evidence” standard when considering evidence for the wishes of patients with impaired capacity to make medical decisions (3-5). To prevent violating the rights of medical autonomy and self-determination for patients receiving long-term opioid therapy for chronic pain, we should apply a “clear and convincing evidence” standard to assess the scientific evidence justifying any proposed health policy seeking to limit patients’ participation in shared medical decision-making.

References

1.Sullivan MD, Linder JA, Doctor JN. Centers for Disease Control and Prevention Guideline for Prescribing Opioids, 2022—Need for Integrating Dosing Benchmarks With Shared Decision-Making. JAMA Intern Med. Published online July 17, 2023. doi:10.1001/jamainternmed.2023.2847.

2.Elwyn G, Price A, Franco JVA, Gulbrandsen P. The limits of shared decision making. BMJ Evid Based Med. 2022 Dec 15:bmjebm-2022-112089. doi: 10.1136/bmjebm-2022-112089. Epub ahead of print. PMID: 36522136.

3.Kollas CD, Kollas BB. Chapter 12: End-of-Life Decision-Making. Holzer, Jacob and others (eds), GERIATRIC FORENSIC PSYCHIATRY: Principles and Practice (New York, 2017; online edn, Oxford Academic, 1 Dec. 2017), https://doi.org/10.1093/med/9780199374656.001.0001. Last accessed on July 20, 2023.

4.Mareiniss DP. A comparison of Cruzan and Schiavo: the burden of proof, due process, and autonomy in the persistently vegetative patient. J Leg Med. 2005 Jun;26(2):233-59.

5.Kollas CD, Boyer-Kollas B. Closing the Schiavo case: an analysis of legal reasoning. J Palliat Med. 2006 Oct;9(5):1145-63.

CONFLICT OF INTEREST: I serve as Chair for the American Medical Association (AMA) Pain & Palliative Medicine Specialty Section Council, as well as the American Academy of Hospice & Palliative Medicine's Delegate to the AMA House of Delegates. I have no financial conflicts of interest to report.

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