The Centers for Disease Control and Prevention (CDC) issued 12 recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
The recommendations are intended to improve communication about the benefits and risks, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy. They were published March 15 by the Journal of the American Medical Association.
The recommendations focused on 3 areas:
Starting or continuing opioids for chronic pain
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioids only if expected benefits for both pain and function outweigh risks to the patient.
2. Before starting opioids, clinicians should establish realistic goals for pain and function, and should consider how therapy will be stopped if benefits do not outweigh risks. 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.
Opioid selection, dosage, duration, follow-up, and discontinuation
4. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release or long-acting opioids.
5. Clinicians should prescribe the lowest effective dosage to start. Clinicians should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid or carefully justify a decision to increase dosage to 90 MME or more per day.
6. When opioids are used for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
7. Clinicians should evaluate benefits and harms within 1 to 4 weeks of starting opioid therapy 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 optimize therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Assessing risk and addressing harms of opioid use
8. Before starting and periodically during continuation of 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 for opioid overdose risk factors such as history of overdose, history of substance use, higher opioid dosages (≥50 MME/d), or concurrent benzodiazepine use.
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 opioid dosages or dangerous combinations that put him or her at high risk for overdose. This should be done when starting opioids and thereafter every 3 months for every prescription.
10. Clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
11. Clinicians should avoid prescribing opioids at the same time as benzodiazepines whenever possible.
12. Clinicians should offer or arrange treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
The authors wrote that more research is needed to fill critical evidence gaps, but noted that “given that chronic pain is a significant public health problem, the risks associated with long-term opioid therapy, the availability of effective alternative treatment options for pain, and the potential for improvement in the quality of health care with the implementation of recommended practices, a guideline for prescribing is warranted with currently available evidence.”
One editorial (among many published with the guidelines) stated that there will likely never be 1 way to treat pain, but noted that no pain is not the goal; rather, it is the reduction of suffering, which is more complex than just analgesia.
A second editorial noted that the CDC guidelines focus on practical ways primary care clinicians can minimize risks of overdose, misuse, and addiction from opioids. “The CDC guideline for prescribing opioids for chronic pain is an important and essential step forward. With support from physicians across the country, as well as from policy makers at all levels, implementation of the recommendations in this guideline has the potential to improve and save many, many lives,” the author said.
ACP issued a statement of support for the guidelines. The CDC included a number of ACP recommendations made in response to a mid-January draft guideline, including acknowledgment of the current limited, but emerging evidence related to the treatment of pain using opioids, recognition of individual patient needs, and recognition of coverage and workforce barriers to non-opioid treatment of pain.