August 2016

CDC Guidelines for Prescribing Opioids for Chronic Pain

Part 2 of a 3-part series describing the new CDC guidelines for prescribing opioids. Part 1 was published in the June issue of the Blue Review.

In March of 2016, the Centers for Disease Control and Prevention (CDC) issued new recommendations for prescribing opioid medications for chronic pain, excluding reasons for cancer, palliative and end-of-life care.¹ These recommendations are in response to an increased need for provider education due to a nationwide epidemic of opioid overdose and opioid use disorder.

The CDC has developed 12 recommendations, grouped into three areas of consideration:

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 use

The second area of consideration – opioid selection, dosage, duration, follow-up and discontinuation – is described below. The third area will be discussed in a future issue of Blue Review.

Opioid Selection, Dosage, Duration, Follow-Up and Discontinuation

1. According to the new guidelines released in March 2016, the CDC recommends that providers start with prescriptions for immediate-release (IR) opioids, instead of extended-release/long-acting opioids (ER/LA) when initiating treatment for chronic pain.
• Immediate-release opioids include:
• Codeine
• Hydrocodone
• Hydromorphone
• Morphine
• Oxycodone
• Extended-release/long-acting opioids include:
• Methadone
• Transdermal fentanyl
• ER versions of oxycodone, oxymorphone, hydrocodone and morphine
• ER/LA medications should be reserved for severe, continuous pain and should only be used in patients who have received IR opioids daily for at least one week.
2. The guidelines also state that providers should start opioid therapy with the lowest effective dosage. Morphine milligram equivalents (MME) more than 50 MME/day should be used with caution, and MME dosages more than 90 MME/day should be avoided when possible, or carefully justified.
• Opioid therapy lower than 50 MME/day has been associated with reduced risk of overdose.
• A morphine equivalent dose calculator can be found at agencymeddirectors.wa.gov/mobile.html.
3. Knowing that long-term opioid use often begins with opioid treatment of acute pain, the CDC recommends that providers use the lowest effective dose of an immediate release product when opioids are being used to treat acute pain. For example, three days of opioid treatment for acute pain is often sufficient, but more than seven days may be too much.
• Evidence has shown that a greater amount of early opioid exposure can be associated with a greater risk of long-term opioid usage.
• Experts have noted that each day of unnecessary opioid use can increase the likelihood of physical dependence without any additional benefit to the patient.
• Prescribing opioids for fewer days can also help minimize the number of extra medication that may be available for potential misuse.
4. Finally, the guidelines say that providers should follow up with patients to evaluate their pain within one to four weeks of starting opioid therapy for chronic pain, or after a dose increase. Continued opioid therapy should be evaluated at least every three months to determine the benefits or potential harmfulness. If the benefits do not outweigh the harmfulness, providers should consider tapering the opioid dosing and consider other possible therapies.
• Contextual evidence has found that patients who do not experience pain relief with opioids in one month are unlikely to experience pain relief with opioids at six months.
• Providers should re-evaluate patients with potential risk of opioid use disorder or overdose more frequently than every three months.

A review on assessing risk and addressing harms of opioid use will be included in next month’s Blue Review.