The federal Centers for Disease Control and Prevention (CDC) issued its draft guidelines for the prescribing of opioids for pain on December 14 in the Federal Register. There is a very short comment period: 30 days, with comments due by January 13.
The guidelines are meant to reduce overprescribing of opioids, which the CDC says should not be used for chronic pain. They are meant for primary care providers (family physicians or internists) who are treating patients for chronic pain in an outpatient setting. They do not apply to methadone or buprenorphine prescribing for the treatment of opioid use disorders. They also do not apply to chronic pain related to palliative or end-of-life care, or to treatment of patients with active cancer. Adherence to the guidelines is voluntary.
It is possible that as chronic pain patients who are dependent on opioids are tapered from or lose the availability of medications, they may move to medication-assisted treatment with methadone or buprenorphine, or other substance use disorder treatment (see ADAW, Nov. 23). When the draft guidelines were released online briefly in September, the pain community, which is working hard to distinguish itself from the “addict” community, objected strongly (see ADAW, Nov. 16).
Below are the 10 guidelines:
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
- Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
- Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
- When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
- When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/day.
- Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers 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. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.
- Providers should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.
- Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers 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 or higher opioid dosages (≥50 MME), are present.
- Providers should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers 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 three months.
- When prescribing opioids for chronic pain, providers 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.
For the full packet of Federal Register materials, including instructions on how to comment, the draft guidelines, stakeholder comments and more, go to http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0001