The CDC has released a guideline for primary care clinicians who are prescribing opioids to patients with chronic pain in instances other than active cancer treatment, palliative care, and end-of-life care. The set of 12 recommendations was published March 15 online ahead of print in JAMA.
The guideline focuses on 3 main areas:
- When to initiate or continue opioids for chronic pain
- Selecting the appropriate opioid and dose, as well as the duration of treatment, follow-up periods, and discontinuation of treatment
- Assessing the risk and addressing the harms of opioid use
The CDC developed its guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. The guideline is a response to clinician concerns about opioid misuse, stress of managing chronic pain patients, patient addiction, and insufficient training regarding opioids.
Determining when to initiate or continue opioids for chronic pain
1. The preferred treatments for chronic pain and nonpharmacologic therapy and nonopioid pharmacologic therapy. Opioid therapy should only be considered if clinicians expect the benefits for both the patient’s pain and function to outweigh the anticipated risks associated with opioids. If a patient is prescribed opioids, clinicians should combine opioid therapy with nonpharmacologic therapy and nonopioid pharmacologic therapy when appropriate.
2. Before initiating opioid therapy for chronic pain, clinicians should work with the patient to determine realistic goals for pain and function, and they should consider how opioid therapy will be discontinued if benefits do not outweigh the risks. Opioid therapy should only be continued if the patient experiences clinically meaningful improvement in pain and function that outweighs opioid-associated risks.
3. Before starting and during opioid therapy, clinicians should talk to patients about the known risks and realistic benefits of opioids as well as responsibilities for managing therapy.
Opioid selection, dosage, duration, follow-up, and discontinuation
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids rather than extended-release/long-acting (ER/LA) opioids.
5. At the beginning of opioid therapy, clinicians should prescribe the lowest effective dosage. While they should use caution with any dose, clinicians should be especially critical of the evidence of individual benefits and risks when considering increasing a patient’s dosage to ≥50 morphine milligram equivalents (MME)/day. Clinicians should avoid increasing dosage to ≥90 MME/day if possible. If not, they should carefully justify the decision to titrate dosage to ≥90 MME/day.
6. When using opioids to treat acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids. No greater quantity than needed for the anticipated duration of severe pain should be prescribed – 3 days or less is often sufficient, with more than 7 days rarely necessary.
7. Within 1 to 4 weeks of starting opioid therapy or escalating the dose, clinicians and patients should evaluate the benefits and harms. Continued evaluation should occur at least once every 3 months. If the benefits do not outweigh the harms of continued therapy, clinicians should work with the patient to lower their opioid dosage or discontinue opioid therapy altogether.
Assessing risk and addressing harms of opioid use
8. Both before starting and during continuation of opioid therapy, clinicians should evaluate the patient’s risk factors for opioid-related harms. Management plan strategies that can reduce risk should be incorporated into the patient’s pain management plan. Clinicians should consider offering naloxone if a patient has factors that increase the risk for opioid overdose, including history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), and concurrent benzodiazepine use.
9. Using state prescription drug monitoring program (PDMP) data, clinicians should review the patients’ history of controlled substance prescriptions to monitor whether they are receiving opioid dosages or drug combinations that put them at a high risk for overdose. PDMP data should be reviewed at the beginning of opioid therapy for chronic pain and periodically during treatment (at least every 3 months).
10. Before starting opioid therapy, patients should undergo urine drug testing to test for prescribed medications, controlled prescription drugs, and illicit drugs. Clinicians should consider urine testing for patients using opioid therapy at least annually to reassess.
11. Whenever possible, clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently.
12. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment.