The Centers for Disease Control and Prevention (CDC) proposed 12 draft recommendations for primary care clinicians who are prescribing opioids for chronic pain not related to cancer treatment, palliative care, and end-of-life care. The proposed guideline was posted Dec. 14 and can be downloaded from the CDC's website. All recommendations are category A (apply to all patients outside of active cancer treatment, palliative care, and end-of-life care) except recommendation 10 (designated category B, with individual decision making required); see the full proposed guideline for evidence ratings. The agency is accepting public comments on the proposed guideline until Jan. 13.
On when to start or continue opioids for chronic pain, the proposed guideline says:
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should only consider opioids if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function. Clinicians should not start opioids without considering how therapy will be stopped if unsuccessful. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
3. Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
On opioid selection, dosage, duration, follow-up, and discontinuation, the proposed guideline says:
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
5. When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/day.
6. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.
7. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should work with patients to reduce opioid dosage and to discontinue opioids.
On assessing risk and addressing harms of opioid use, the proposed guideline says:
8. Before starting and periodically during opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or higher opioid dosage (≥50 MME) are present.
9. Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put the person at high risk for overdose. This should be done when starting opioid therapy and periodically afterward, ranging from a check at every prescription to every 3 months.
10. Clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for use of prescribed medications as well as other controlled prescription drugs and illicit drugs.
11. Clinicians should, whenever possible, avoid prescribing opioid pain medication for patients receiving benzodiazepines.
12. Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
In an unrelated research letter that appeared in JAMA Internal Medicine on Dec. 14, study authors used 2013 Medicare data to find that internists and family medicine physicians prescribed more opioids than any other specialty, even though prescriptions for opioid pain relievers were concentrated in specialties for pain, anesthesia, and physical medicine and rehabilitation. The authors focused on prescriptions of hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium, or levorphanol.
Opioid prescriptions were concentrated in the specialties of interventional pain management (1,124.9 prescriptions per prescriber), pain management (921.1 prescriptions per prescriber), anesthesiology (484.2 prescriptions per prescriber) and physical medicine and rehabilitation (348.2 prescriptions per prescriber), according to the results. However, based on total claims, the most prescriptions were written by clinicians in family practice (15.3 million), internal medicine (12.8 million), nurse practitioners (4.1 million) and physician assistants (3.1 million).
“High-volume prescribers are not alone responsible for the high national volume of opioid prescriptions. Efforts to curtail national opioid overprescribing must address a broad swath of prescribers to be effective,” the research letter concluded.