CDC: Think long and hard before prescribing opioids for chronic pain

Trying to curb widespread opioid abuse that claimed nearly 20,000 U.S. lives last year alone, the Centers for Disease Control and Prevention (CDC) is telling primary care clinicians to prescribe treatments other than opioids for chronic pain outside of active cancer treatment, palliative care and end-of-life care.

The new CDC opiod prescription guidelines are intended for use outside of acute care settings.

A Special Communication from the CDC published online in the Journal of the American Medical Association (JAMA) outlines 12 recommendations divided into three categories.

They are:

Determining when to initiate or continue opioids for chronic pain:

1. Consider opioid therapy only if expected benefits for both pain and function are expected to outweigh risks to the patient.
2. Establish treatment goals with all patients, including realistic goals for pain and function, and consider how to discontinue therapy if risks outweigh benefits.
3. Discuss risks and realistic benefits of opioid therapy with patients, as well as patient and clinician responsibilities for managing therapy.

Opioid selection, dosage, duration, follow-up and discontinuation:

4. At the beginning of opioid therapy for chronic pain, prescribe immediate-release opioids instead of extended-release/long-acting opioids.
5. Prescribe the lowest effective dosage and use caution when prescribing opioids at any dosage. Carefully reassess benefits and risk when increasing dosage to 50 morphine milligram equivalents (MME) or more per day and avoid increasing dosage to 90 MME or more per day.
6. Limit opioid prescriptions for acute pain--more than seven days' worth is rarely needed.
7. Evaluate benefits and harms with patients as early as one week and no more than four weeks after starting therapy for chronic pain or escalating doses, and again after no more than three months. Taper dosages or discontinue opioids if necessary.

Assessing risk and addressing harms of opioid use:

8. Incorporate into the opioid therapy management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for overdose are present.
9. Use state prescription drug monitoring program (PDMP) data to see whether a patient is getting opioids from other providers at dosages or in combinations with other drugs that create a high risk of overdose. 
10. Order urine drug testing before starting opioid therapy and consider repeating at least annually.
11. Avoid prescribing opioid pain medication and benzodiazepines at the same time whenever possible.
12. Offer or arrange evidence-based treatment for patients with opioid use disorder.

A companion commentary in JAMA contends that part of the problem is that doctors aren't well trained about addiction either in medical school or in continuing education. It also cites "enormous gaps in reimbursement" for both chronic pain and addiction treatment.

"The CDC guideline for prescribing opioids for chronic pain is an important and essential step forward," it says. "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."

Just last month the American Medical Association issued its own suggested changes for practitioners to tackle the opioid addiction crisis, as FiercePracticeManagement reported. Like the CDC, the AMA recommended clinicians use PDMP data routinely. 

As the CDC notes in its new guidelines, primary care clinicians can help avert possible abuse by communicating with patients before prescribing opioids to learn about any personal or family history of addiction, and to determine whether patients even want opioid painkillers, FiercePracticeManagement previously reported.

To learn more:
- here's the guideline
- read the JAMA Special Communication
- check out the commentary