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Best Practices in Prescribing Opioids for Chronic Pain

Best Practices in Prescribing Opioids for Chronic Pain

It is estimated that chronic pain affects 11.2 percent of adults in the U.S. Opioids are commonly prescribed for chronic pain, despite their increased risks for addiction, overdose, and death as compared with other pain management strategies.

Research shows that opioids do have some short-term efficacy and they can offer patients pain relief, but few studies have examined the long-term benefits of opioids for chronic pain, according to the Centers for Disease Control and Prevention (CDC), which in 2016 issued recommended prescribing guidelines for opioids. The guidelines are based on an analysis of newly published observational studies and randomized clinical trials, plus clinical experience and observations.

Led by Deborah Dowell, M.D., of the CDC’s National Center for Injury Prevention and Control, the CDC committee generated 12 recommendations in three areas:  determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use.

The guidelines, which are recommended and not intended as prescriptive standards, are intended for primary care clinicians (family physicians, internists, nurse practitioners, and physician assistants) who treat adult patients with chronic pain beyond the scope of end-of-life care, palliative treatment, and active cancer treatment. The guidelines did not address recommendations for specialists.

Writing in an editorial that accompanied the guidelines, Yngvild Olsen, M.D., of the Institutes for Behavior Resources Inc., spoke of the lack of support for primary care practitioners who care for patients with chronic pain.

“In the face of limited, low-quality evidence for the effectiveness of long-term chronic opioids, the CDC guidelines focus on practical ways primary care practitioners can minimize risks of overdose, misuse, and addiction from these medications,” writes Olsen. “There is an innovation gap, with few available care models that give primary care practitioners the time, resources, and support to care for patients with complex chronic pain at risk for or with addiction.”

She notes that in 2014, close to 20,000 deaths were attributed to overdoses from prescription opioids. In that same year, nearly 2 million people met the diagnostic criteria for opioid substance use disorder. 

Dr. Olsen goes on to write that more research is needed on how to best assess the quality of pain medication prescribing, reduce stigma among physicians and patients around opioid use, and effectively manage co-occurring chronic pain and addiction. 

The guidelines are comprehensive, so here, we highlight some of the key points.

Nonpharmacologic and nonopioid therapy. Outside of cancer, palliative care, and end-of-life treatment, opioids should never be the first-line therapy. As appropriate, the committee recommends that nonpharmacologic approaches such as exercise therapy and cognitive behavioral therapy (CBT) be explored before opioids are prescribed. Additionally, nonopioid pharmacologic therapy such NSAIDs or acetaminophen should be combined with nonpharmacologic therapy when the benefits outweigh the risks.

Patient-provider communication and shared decision making. Before opioid therapy begins, clinicians should talk with their patients to establish goals for chronic pain treatment. Clinicians should also have a candid discussion about how and when opioids will be discontinued if the benefits do not outweigh the risks.

Frequent monitoring. Clinicians should evaluate the benefits and harms of continued opioid therapy with patients approximately every three months or more to minimize risks and potential for opioid use disorder.

Drug testing. Before starting opioid therapy, clinicians should consider urine testing to screen for current drug use that may put the patient at increased risk for an overdose if combined with opioids. After opioids are initiated, urine testing should be done annually to help avoid substance use disorders.

Lowest dosage possible. If opioids are used with patients, the clinician should prescribe the lowest effective dose possible. If dosing will be increased to 50-morphine milligrams or more per day, the clinician should carefully reevaluate the risk-benefit ratio.

Avoid concurrent opioids and benzodiazepines. Whenever possible, clinicians should avoid prescribing this combination of drugs. If patients are on both drugs and need to be tapered off one of them or both, it is safer to taper the opioids first.

Resources for opioid use disorder.  For patients who have an opioid use disorder, clinicians should offer support services or arrange for the patient to receive evidence-based treatment such as medication-assisted treatment with buprenorphine or methadone.

Other important findings:

  • When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release or long-acting opioids.
  • When used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and prescribe no greater quantity than needed for the expected duration of pain. Three days or less is often sufficient, whereas more than seven days is rarely needed.
  • Before starting opioids and with ongoing opioid therapy, clinicians should evaluate risk factors for opioid-related harms, including offering naloxone when factors exist that increase the risk for opioid overdose such as a history of substance use disorder.
  • Clinicians should evaluate the patient’s history of controlled substance prescriptions and check the prescription drug monitoring program data for prescriptions written by other clinicians.
 

Disclosures

This research was funded in part by the Centers for Disease Control and Prevention.

Drs. Dowell and Haegerich are employees of the Centers for Disease Control and Prevention. Dr. Chou was supported under contract through a detail at CDC.

 

References

  1. Deborah Dowell, Tamara Haegerich, Roger Chou. “CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016,JAMA. Published April 19, 2016. DOI: 10.1001/jama.2016.1464
  2. Yngvild Olsen. “The CDC Guideline on Opioid Prescribing,” JAMA. Published April 16, 2016. DOI: 10.1001/jama.2016.1910
  3. Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American Pain Society and American Academy of Pain Medicine. http://americanpainsociety.org/uploads/education/guidelines/chronic-opio... -cncp.pdf. Accessed February 6, 2016.
  4. Anastassopoulos KP, ChowW, Tapia CI, Baik R, Moskowitz B, KimMS. Reported side effects, bother, satisfaction, and adherence in patients taking hydrocodone for non-cancer pain. J Opioid Manag. 2013;9(2):97-109.
  5. Gregorian RS Jr, Gasik A, KwongWJ, Voeller S, Kavanagh S. Importance of side effects in opioid treatment: a trade-off analysis with patients and physicians. J Pain. 2010;11(11):1095-1108.
  6. Thielke SM, Turner JA, Shortreed SM, et al. Do patient-perceived pros and cons of opioids predict sustained higher-dose use? Clin J Pain. 2014;30(2): 93-101.
  7. Chou R, Deyo R, Devine B, et al. The effectiveness and risks of long-term opioid treatment of chronic pain [Evidence Report/Technology Assessment No. 218]. Agency for Healthcare Research and Quality. http://www.effectivehealthcare.ahrq.gov/ehc/products/557/1971/chronic-pa.... Accessed February 2, 2016.
  8. Multiple cause of death data. CDCWONDER. Centers for Disease Control and Prevention. http://wonder.cdc.gov/mcd.html. Accessed February 26, 2016.

 

 
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