CDC Issues New Opioid Management Guidelines This Week

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:

  1. Determining when to initiate or continue opioids for chronic pain
  2. Opioid selection, dosage, duration follow up and discontinuation
  3. Assessing risk and addressing harms of opioid us

SUMMARY OF RECOMMENDATIONS

  1. Non pharmacologic therapy and non-opioid therapy are preferred for chronic pain
  2. Treatment goals should be established before starting opioids
  3. Discussion before and periodically during opioid therapy should occur on known risks and realistic benefits
  4. When starting opioid therapy, start with immediate release formulations rather than extended/ long acting opioids
  5. 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
  6. For acute pain, prescribe no more than 3 – 7 days of opioid analgesia. More is rarely needed
  7. Evaluate benefit within 1-4 weeks of starting, then every 3 months. If benefits not achieved, taper doses rather than escalating.
  8. 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
  9. 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.
  10. Use urine drug testing before starting opioid therapy and at least annually during chronic therapy to assess for prescribed and illicit durgs.
  11. Avoid concurrent use of opioid medications with benzodiazepines
  12. 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.

  1. http://www.cdc.gov/drugoverdose/prescribing/guideline.html

 

One thought on “CDC Issues New Opioid Management Guidelines This Week

  1. I do not deny the risks of prescribed opiates. I openly admit that for many years I was part of the problem and to some degree I still am in that I still have a few patients on high doses. I am quite concerned, however, about the switch to NSAIDs. In recent months I am seeing an increased frequency of patients with NSAID induced GI bleed as well as new and worsening renal insufficiency (CKD). I have also seen a number of patients with known CKD, many of whom are taking ACE-Is, prescribed NSAIDs upon leaving ER or hospital or consultants’ offices. My sample is small enough that this all could be coincidence. I haven’t kept specific records so I’m not able to analyze my observations. However, I am very concerned that we are trading one method of harming patients for another.

    For years I have been telling my patients that I wish someone would invent just one pain medicine that is safe and effective. We have had, and continue to have, nothing to offer our patients. The adjunctive medications help some people and are well tolerated by a few. They generally seem to be safer than acetaminophen or NSAIDs or opiates, but they are far from benign.

    Non-pharmacologic therapies certainly are at least as effect as — and way safer that — any drug in that small cohort who can access them and will follow through with them. My patients who live in the city have reasonable concern about getting mugged if they try to exercise outdoors. Those who live in the country have reasonable concern about getting run over on shoulder-less roads if they try to exercise outdoors. If they can access mental health services those are limited to brief visits with psychiatrists who are afforded no time for counseling. LCSWs, MFTs, and psychologists are effectively non-existent for my patients who qualify for Medi-Cal/Partnernship.

    I have long known that the pain management care that I have offered (pills) is inadequate and largely inappropriate. I’m still waiting to be able to offer more even though I know better know what that should look like.

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