September 2016

CDC Guidelines for Prescribing Opioids for Chronic Pain

Part 3 of a 3-part series describing the new CDC guidelines for prescribing opioids. Part 1 and 2 were previously published.

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 were 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:

• 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

The first and second areas of consideration were discussed previously. The third area of consideration – assessing risk and addressing harms of opioid use – is described below.

Assessing Risk and Addressing Harms of Opioid Use

1. Before starting opioid therapy and during treatment, providers should assess the risk for opioid-related harms. Providers should evaluate strategies, such as offering naloxone, if there is an increased risk of opioid overdose due to history of overdose, high opioid dosages or concurrent benzodiazepine use.

   • Special populations that may be at higher risk of opioid related harms include: patients with sleep-disordered breathing (including sleep apnea), pregnant women, patients with renal or hepatic insufficiency, patients aged 65 years or older, patients with mental health conditions, patients with substance abuse disorder and patients with prior nonfatal overdose.
   • Naloxone, an opioid antagonist that can reverse severe respiratory depression, can save lives if used properly for opioid overdose. Friends and family who administer naloxone must be properly trained. Experts agree that providers should consider offering naloxone when prescribing opioids to patients at increased risk of opioid overdose, including patients with a history of overdose, substance abuse disorder or taking benzodiazepines with opioids. Resources for prescribing naloxone in a primary care setting can be found through Prescribe to Prevent at prescribetoprevent.org.

2. Providers should utilize state prescription drug monitoring program (PDMP) data and assess patient opioid history to determine whether or not there are any dangerous drug combinations occurring or if the patient is receiving unsafe quantities of controlled substances.

   • PDMPs are state-based databases that collect information on controlled prescription drugs dispensed by pharmacies and in some cases by dispensing physicians. The Texas Prescription Monitoring Program is located at TexasPATX.com.
   • Before an opioid prescription is written and dispensed, providers and pharmacists should review PDMP data to see if the patient is receiving high total opioid dosages or dangerous combinations that put the patient at risk for overdose.

3. Before starting opioid treatment, providers should use urine drug testing to assess whether or not the patient is already on controlled or illicit substances. The provider may want to consider urine testing at least annually as well.

   • Opioid pain medications in combination with other opioid pain medications, benzodiazepines or illicit substances can put the patient at increased risk of overdose and opioid related harms. Urine drug tests can provide information that the patient does not provide and can help detect drug seeking behaviors.
   • Providers can use urine drug test results to help with patient safety by tapering or discontinuing opioids if the member is at risk of opioid use disorder, offering naloxone or referring for behavioral treatment for substance use disorder.

4. As much as possible, providers should avoid prescribing opioid pain medication and benzodiazepines concurrently.

   • Concurrent benzodiazepine and opioid use can cause central nervous system and respiratory depression.
   • If opioid treatment is needed, providers should taper benzodiazepines gradually to prevent rebound side effects.

5. For patients with opioid use disorder, providers should offer to help with evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone combined with behavioral therapies.

   • Clinical evidence has found that opioid dependence in primary care settings is between three and 26 percent among patients with chronic pain on opioid therapy.
   • Contextual evidence has found opioid agonist or partial agonist treatment with methadone maintenance therapy or buprenorphine may be helpful in preventing relapse in patients with opioid use disorder. Behavioral therapy with medication treatment is also recommended by clinical practice guidelines.
   • Physicians must be certified to provide buprenorphine in an office-based setting. Physicians can receive training to receive a waiver from the Substance Abuse and Mental Health Services Administration.

¹Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain- United States, 2016. MMWR Recomm Rep 2016; 65:1-49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.