CDC_Guidelines

CDC Opioid Prescription Guidelines for
Chronic Pain
David P. Russo, DO, MPH
Columbia Pain Management, PC

Who is the CDC?
• Center for disease
control and prevention
• Primary Federal public
health agency
– Historically focused on
infectious diseases
– Now includes
occupational,
environmental, and
some chronic diseases

The Recent Past
• Entrapment and prosecution of prescribing physicians
was common for “over-prescribing.”
• Addiction was seen as
a law enforcement
issue and outside the
realm of medical practice.
• 88% of medical board members surveyed in 1991
believed that extended opioid prescribing was unlawful
and unacceptable medical practice for persons with
chronic non cancer pain. 1
• 1. Gilson AM, Joranson DE. Controlled substances and pain management: changes in knowledge and attitudes of state medical
regulators. J Pain Symptom Manage 2001;21(3):227–37.

Treatment of pain:
Big concern and big business
• Mid-90’s we were told that we were doing an
inadequate job controlling pain. Oxycontin was
released in 1996.
– Early 2000’s JCAHO makes “Pain Assessment” an indicator of good
quality.
– “Chronic Pain” gets its own ICD-9 code
• Pain score becomes a vital sign.
• 2001 Oxycontin is best selling opioid.
– 2003 NEJM encourages more liberal prescribing practices: Claiming
such practices do no harm.

Oregon Board Disciplines Doctor
for Not Treating Patients' Pain
“In what appears to be the first such action in
the nation, the Oregon Board of Medical
Examiners this week disciplined a doctor for
insufficiently treating pain in his patients.”
September 4, 1999

Over-treatment is the new Under-treatment
• Americans are 4.6% of the world's population, but
consume 80% of the world's opioids and 99% of the
world's supply of hydrocodone (i.e., Vicodin).
• 3-4% of Americans use opioids chronically
• >95% of all prescribed opioids are prescribed for
non-cancer pain

Opioid-related Deaths Track Sales

Organization of Recommendations
 The 12 recommendations are grouped into three conceptual
areas:
• Determining when to initiate or continue opioids for chronic pain
• Opioid selection, dosage, duration, follow-up, and discontinuation
• Assessing risk and addressing harms of opioid use
 CDC Convened Core Expert Group who rated evidence
 GRADE Methodology
• A = applies to everyone in specified group; most should receive it
• B = individual decision making; consider patient values & preferences
• 1-4 = 1 strongest evidence; 4 is weakest evidence available

DETERMINE WHEN TO INITIATE OR
CONTINUE OPIOIDS FOR CHRONIC PAIN

Recommendation #1
 Nonpharmacologic therapy and nonopioid pharmacologic
therapy are preferred for chronic pain.
 Clinicians should consider opioid therapy only if expected
benefits for both pain and function are anticipated to
outweigh risks to the patient.
 If opioids are used, they should be combined with
nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.
(Recommendation category A: Evidence type: 3)

Opioids not first-line or routine therapy for chronic pain
 Use nonpharmacologic therapy such as exercise or cognitive
behavioral therapy (CBT) to reduce pain and improve
function.
 Use nonopioid pharmacologic therapy (nonsteroidal anti-
inflammatory drugs, acetaminophen, anticonvulsants,
certain antidepressants) when benefits outweigh risks,
combined with nonpharmacologic therapy.
 When opioids used, combine with nonpharmacologic
therapy and nonopioid pharmacologic therapy to provide
greater benefits.

Recommendation #2
 Before starting opioid therapy for chronic pain, clinicians
should establish treatment goals with all patients, including
realistic goals for pain and function, and should consider
how therapy will be discontinued 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.

Establish and measure progress toward goals
 Before initiating opioid therapy for chronic pain
• Determine how effectiveness will be evaluated.
• Establish treatment goals with patients.
o Pain relief
o Function
 Assess progress using 3-item PEG Assessment Scale*
• Pain average (0-10)
• Interference with Enjoyment of life (0-10)
• Interference with General activity (0-10)
 *30% = clinically meaningful improvement

Recommendation #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.

Ensure patients are aware of potential benefits,
harms, and alternatives to opioids
 Be explicit and realistic about expected benefits.
 Emphasize goal of improvement in pain and function.
 Discuss
• serious and common adverse effects
• increased risks of overdose
o at higher dosages
o when opioids are taken with other drugs or alcohol
• periodic reassessment, PDMP and urine checks; and
• risks to family members and individuals in the community.

OPIOID SELECTION, DOSAGE,
DURATION, FOLLOW-UP, AND
DISCONTINUATION

Recommendation #4
 When starting opioid therapy for chronic pain, clinicians
should prescribe immediate-release opioids instead of
extended-release/long-acting (ER/LA) opioids.

Choose predictable pharmacokinetics and
pharmacodynamics to minimize overdose risk
 In general, avoid the use of immediate-release opioids
combined with ER/LA opioids.
 Methadone should not be the first choice for an ER/LA
opioid.
• Only providers familiar with methadone’s unique risk and who are
prepared to educate and closely monitor their patients should
consider prescribing it for pain.
 Only consider prescribing transdermal fentanyl if familiar
with the dosing and absorption properties and prepared to
educate patients about its use.

Recommendation #5
 When opioids are started, clinicians should prescribe the
lowest effective dosage.
 Clinicians should use caution when prescribing opioids at
any dosage, should carefully reassess evidence of individual
benefits and risks when increasing dosage to ≥50 morphine
milligram equivalents (MME)/day, and should avoid
increasing dosage to ≥90 MME/day or carefully justify a
decision to titrate dosage to >90 MME/day.

Start low and go slow
 Start with lowest effective dosage and increase by the smallest
practical amount.
 If total opioid dosage >50 MME/day
• reassess pain, function, and treatment
• increase frequency of follow-up; and
• consider offering naloxone.
 Avoid increasing opioid dosages to >90 MME/day.
 If escalating dosage requirements
• discuss other pain therapies with the patient
• consider working with the patient to taper opioids down or off
• consider consulting a pain specialist.

If patient is already receiving a high dosage
 Offer established patients already taking >90 MME/day the
opportunity to re-evaluate their continued use of high
opioid dosages in light of recent evidence regarding the
association of opioid dosage and overdose risk.
 For patients who agree to taper opioids to lower dosages,
collaborate with the patient on a tapering plan.

Recommendation #6
 Long-term opioid use often begins with treatment of acute
pain.
 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.
 3 days or less will often be sufficient; more than 7 days will
rarely be needed.

When opioids are needed for acute pain
 Prescribe the lowest effective dose.
 Prescribe amount to match the expected duration of pain
severe enough to require opioids.
 Often < 3 days and rarely more than 7 days needed.
 Do not prescribe additional opioids “just in case”.
 Re-evaluate patients with severe acute pain that continues
longer than the expected duration to confirm or revise the
initial diagnosis and to adjust management accordingly.
 Do not prescribe ER/LA opioids for acute pain treatment.

Recommendation #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 optimize other therapies and work
with patients to taper opioids to lower dosages or to taper
and discontinue opioids.

Follow-up
 Re-evaluate patients
• within 1-4 weeks of starting long-term therapy or of dosage
increase
• at least every 3 months or more frequently.
 At follow up, determine whether
• opioids continue to meet treatment goals
• there are common or serious adverse events or early warning
signs
• benefits of opioids continue to outweigh risks
• opioid dosage can be reduced or opioids can be discontinued.

Tapering Opioids
 Work with patients to taper opioids down or off when
• no sustained clinically meaningful improvement in pain and
function
• opioid dosages >50 MME/day without evidence of benefit
• concurrent benzodiazepines that can’t be tapered off
• patients request dosage reduction or discontinuation
• patients experience overdose, other serious adverse events,
warning signs.
 Taper slowly enough to minimize opioid withdrawal
• A decrease of 10% per week is a reasonable starting point
 Access appropriate expertise for tapering during pregnancy
 Optimize nonopioid pain management and psychosocial support

ASSESSING RISK AND ADDRESSING
HARMS OF OPIOID USE

Recommendation #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 when factors that increase risk for opioid
overdose, such as history of overdose, history of substance
use disorder, higher opioid dosages (>50 MME/day), or
concurrent benzodiazepine use, are present.

Certain factors increase risks for opioid-associated
harms
 Avoid prescribing opioids to patients with moderate or severe sleep-
disordered breathing when possible.
 During pregnancy, carefully weigh risks and benefits with patients.
 Use additional caution with renal or hepatic insufficiency, aged >65
years.
 Ensure treatment for depression is optimized.
 Consider offering naloxone when patients
• have a history of overdose
• have a history of substance use disorder
• are taking central nervous system depressants with opioids
• are on higher dosages of opioids (> 50 MME/day).

Recommendation #9
 Clinicians should review the patient’s history of controlled
substance prescriptions using state PDMP data to determine
whether the patient is receiving opioid dosages or
dangerous combinations that put him/her at high risk for
overdose
 Clinicians should review PDMP data when starting opioid
therapy for chronic pain and periodically during opioid
therapy for chronic pain, ranging from every prescription to
every 3 months.

If prescriptions from multiple sources, high dosages,
or dangerous combinations
 Discuss safety concerns with patient (and any other prescribers
they may have), including increased risk for overdose.
 For patients receiving high total opioid dosages, consider tapering
to a safer dosage, consider offering naloxone.
 Consider opioid use disorder and discuss concerns with your
patient.
 If you suspect your patient might be sharing or selling opioids and
not taking them, consider urine drug testing to assist in
determining whether opioids can be discontinued without causing
withdrawal.
 Do not dismiss patients from care—use the opportunity to
provide potentially lifesaving information and interventions.

Recommendation #10
 When prescribing opioids for chronic pain, 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.
(Recommendation category B: Evidence type: 4)

Use UDT to assess for prescribed opioids and other
drugs that increase risk
 Be familiar with urine drug testing panels and how to interpret results.
 Don’t test for substances that wouldn’t affect patient management.
 Before ordering urine drug testing
• explain to patients that testing is intended to improve their safety
• explain expected results; and
• ask patients whether there might be unexpected results.
 Discuss unexpected results with local lab and patients.
 Verify unexpected, unexplained results using specific test.
 Do not dismiss patients from care based on a urine drug test result.

Recommendation #11
 Clinicians should avoid prescribing opioid pain medication
and benzodiazepines concurrently whenever possible.

Avoid concurrent opioids and benzodiazepines
whenever possible
 Taper benzodiazepines gradually.
 Offer evidence-based psychotherapies for anxiety.
• cognitive behavioral therapy
• specific anti-depressants approved for anxiety
• other non-benzodiazepine medications approved for anxiety
 Coordinate care with mental health professionals.

Recommendation #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.

If you suspect opioid use disorder (OUD)
 Discuss with your patient and provide an opportunity to disclose
concerns.
 Assess for OUD using DSM-5 criteria. If present, offer or arrange
MAT.
• Buprenorphine through an office-based buprenorphine treatment
provider or an opioid treatment program specialist
• Methadone maintenance therapy from an opioid treatment
program specialist
• Oral or long-acting injectable formulations of naltrexone (for
highly motivated non-pregnant adults)
 Consider obtaining a waiver to prescribe buprenorphine for OUD (see
http://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management)

Criticisms and Critiques of Guidelines
• Many groups criticized guidelines (AMA, ACP,
APS, AAPM, patient advocacy groups)
– Primary care point of service focus may not be
relevant for specialists
– Potential COI and biases of expert group
– Too many recommendation are Grade A despite
weakest evidence
– Dose recommendations are inflexible and conflict
with physician judgment and personalized care of
the total patient.

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