The Centers for Disease Control and Prevention (CDC) issued national guidelines for Prescribing Opioids for Chronic Pain on March 15th in the MMWR1. This extensive document summarizes the state of the evidence on chronic pain management and the role and dangers of using opioid medications in its management. CDC provided 12 recommendations in three categories that includes:
- 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 us
SUMMARY OF RECOMMENDATIONS
- Non pharmacologic therapy and non-opioid therapy are preferred for chronic pain
- Treatment goals should be established before starting opioids
- Discussion before and periodically during opioid therapy should occur on known risks and realistic benefits
- When starting opioid therapy, start with immediate release formulations rather than extended/ long acting opioids
- Use the lowest effective dose. Caution should be used at any dose, and risks and benefits assessed when using > 50 morphine equivalents. Avoid using doses > 90 morphine equivalents or be clear in justification for escalating doses about 90 MED
- For acute pain, prescribe no more than 3 – 7 days of opioid analgesia. More is rarely needed
- Evaluate benefit within 1-4 weeks of starting, then every 3 months. If benefits not achieved, taper doses rather than escalating.
- Assess potential harms of opioid use and offer naloxone when there are increased risk factors for opioid overdose such as history of overdose, history of substance use disorder, higher opioid dose > 50 MED or concurrent use of benzodiazepines
- Review that state Prescription Drug Monitoring Program database at start of therapy and periodically, at least every six months, to determine if patient is receiving opioid drugs and dosages (and combinations) that put the patient at risk for overdose.
- Use urine drug testing before starting opioid therapy and at least annually during chronic therapy to assess for prescribed and illicit durgs.
- Avoid concurrent use of opioid medications with benzodiazepines
- If the patient has been diagnosed with opioid use disorder, offer the patient medication assisted treatment (MAT) with buprenorphine or methadone in combination with behavioral therapies.
LESSONS FOR YOUR PRACTICE
These new guidelines emphasize many of the strategies promoted by Partnership HealthPlan including use of short acting, monitoring with urine screens and review of CURES, referrals for MAT when appropriate. New in these guidelines is the tightening of excessive dose limits to 90 MED with under 50 MED preferred. Previous guidelines have set this bar at 120-200 MED. CDC notes that even at lower dose ceilings, there is substantial risk for overdose. For instance, the risk of overdose at 50 MED is 2x the risk at 20 MED.