June 1, 2016

New CDC Guidelines for Prescribing Opioids for Chronic Pain

Part 1 of a 3-Part Series: Determining When to Initiate or Continue Opioids for Chronic Pain

This article is a direct summarization of the 2016 CDC Guidelines for Prescribing Opioids for Chronic Pain¹.

In March 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. 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:

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

Determining When to Initiate or Continue Opioids for Chronic Pain

1. The CDC recommends non-pharmacologic and non-opioid pharmacologic therapy as the preferred treatment for chronic pain. In terms of pain relief and function, health care clinicians should weigh the benefits versus the risk when using opioid therapy. If a clinician decides to use opioid therapy, non-pharmacologic and non-opioid pharmacologic therapy should also be incorporated, when possible.
    
   
   • Non-pharmacologic therapies can include: physical therapy, weight loss for knee osteoarthritis, psychological therapies such as CBT and exercise therapy
   • Non-opioid pharmacologic therapy can include: acetaminophen, NSAIDs, and certain antidepressant and anticonvulsant medications
   • Comprehensive pain management may include: a coordination of different specialties including primary care, mental health, physical therapy and social work
     

2. Clinicians should establish realistic goals for pain relief and function with the patient before starting opioid therapy. Prior to starting therapy, patients should be engaged in conversation about how their opioid therapy may be discontinued (i.e., an exit strategy) if the benefits do not outweigh the risks. Opioid therapy should only be continued if there are clinically meaningful improvements in pain and function that outweigh any risks to patient safety.
    
   
   • Patients should understand that while opioid therapy can reduce pain short term, there is no solid evidence that opioids will continue to improve pain and function with long-term use.
   • Clinicians may not want to prescribe opioids for longer than 30 days to ensure that the patient’s pain is reassessed at intervals.
   • Measuring improvements in function can include emotional, social and physical dimensions.
     

3. Clinicians should also ensure that patients are aware of all serious adverse side effects of opioid use, as well as the more common side effects of opioids and how to alleviate them. Additionally, the clinician should review with patients the responsibilities of managing opioid therapy and include them in the final decision of whether or not to start, or continue, opioid therapy.
    
   
   • Serious adverse side effects of opioids can potentially include fatal respiratory depression and/or opioid use disorder that can be life-long and cause major distress.
   • Common side effects of opioids can include: constipation, dry mouth, nausea, vomiting, drowsiness, confusion, tolerance, physical dependence and withdrawal symptoms when stopping opioid therapy.
   • Given the risks, clinicians should review the risks and possible diminished benefits of continued opioid therapy with patients on a periodic basis, at least once every three months.

Stay tuned for next month’s Blue Review for a review on opioid selection, dosage, duration, follow up and discontinuation.

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: dx.doi.org/10.15585/mmwr.rr6501e1.