Patients Prescribed Opioids for Acute Pain
Clinicians and hospital systems should have mechanisms in place to provide timely follow-up with individuals receiving opioid therapy for acute pain. The 2022 CDC draft revision states that patients be evaluated at least every 2 weeks if they continue to receive opioids for acute pain. Adhering to frequent and early follow-up may minimize any unintended impacts on patients of an unexpectedly prolonged duration of severe acute pain.¹ Timely follow-up may also help reduce a potential source of opioid misuse and diversion.²
This recommendation is in stark contrast with the 2016 CDC recommendations, in which there was an emphasis on treatment of chronic pain. The earlier guideline stated specifically: “some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists, but use in these settings or by other specialists is not the focus of this guideline.”
Patients Prescribed Opioids for Subacute and Chronic Pain
When scheduling follow-up visits for subacute and chronic pain, clinicians are advised to evaluate benefits and risks with patients within 1 to 4 weeks of starting opioid therapy, or of any dose escalation. This reassessment within 1 month provides an opportunity to modify the treatment plan and further minimize risks of long-term opioid use. These follow-up recommendation times are unchanged from the 2016 recommendations.
We agree with the new 2022 CDC recommendations on monitoring patients with acute, subacute, and chronic pain conditions in general, but especially those prescribed opioids at any stage. However, quality clinical trial evidence is still very much lacking in regard to specific timing of follow-up and associated opioid-related adverse events, including respiratory depression/overdose, opioid misuse, development of opioid use disorder, and opioid-induced constipation, among others.
Due to the lack of sufficient evidence on specific follow-up timeframes, we are reminded that the above recommendations by the CDC are not mandatory. While we agree that the information provided is reasonable and reflects common practice, clinician judgment is advised.
The current CDC guidelines recommend several topics be discussed with each patient during follow-up visits. Conversations with patients on opioid therapy should address, and re-address:
- respective treatment goals
- the source of pain
- common side effects
- risk of overdose
We suggest that motivational interviewing techniques be used. Specific questions to ask in each topic area are described below.
Patient Behavior, and Lifestyle
It is essential that clinicians review patient perspectives and goals at each visit and determine whether opioid treatment continues to meet intended goals. Clinicians should ask patients about their preferences for continuing opioids, given their effects on pain and function relative to any adverse effects experienced.
It is also important to monitor changes in social behavior and healthy lifestyles. Clinicians should continue to ask patients about drug and alcohol use and provide specific counseling on increased risks for overdose when opioids are combined with other substances. They should ensure that patients are provided with and receive effective treatment for substance use disorders when needed. Clinicians should also routinely ask about endocrine effects and possibility of, or plan for future pregnancy, as some studies have shown an association of opioid use in pregnancy with stillbirth, poor fetal growth, pre-term delivery, and birth defects.⁴
While opioids certainly act on CNS depression, and can be associated with increased risk of depression, caution should be taken to link them to causation, especially in the context of longer-term opioid therapy. In these cases, the patients may also be living with chronic pain, which can also be associated with depression.
The 2022 draft guideline recommends routine follow-up on common opioid side effects (constipation, dry mouth, nausea, vomiting, drowsiness) to further improve quality of life (QoL).
If risks outweigh benefits of continued opioid use, it is important to consider either rotating to a new opioid (if there appropriate and safe to do so) or beginning the process of an opioid taper when possible. To aid in this process, the three-item “Pain average, interference with Enjoyment of life, and interference with General activity” (PEG) Assessment Scale, can help to assess function, pain control, and QoL.⁵
The 2022 CDC updated recommendations suggest that clinicians review a patient’s history of controlled substance prescriptions. State prescription drug monitoring programs (PDMPs) can aid clinicians in determining whether a patient is receiving opioid dosages or combinations from other providers that put them at high risk for overdose.
Consistent with its 2016 guidelines, the CDC continues to recommend that PDMP data be reviewed prior to every opioid prescription for acute, subacute, or chronic pain and again with each visit. At a minimum, PDMP data should be reviewed every 4 months for those individuals receiving long-term opioid therapy.
Clinicians should note that, if entered incorrectly, PDMP information may provide inaccurate information (eg, wrong name or birthdate, information falling under a patient’s nickname or maiden name, identity theft to obtain prescriptions).⁸ It is important to note that PDMPs now exist in most but not all US jurisdictions.
Finally, PDMP results that are unexpected (ie, patient prescribed a controlled substance from a different provider) should always be verified with the pharmacy/provider and should always be discussed with the patient prior to any clinical decisions being made (especially abrupt discontinuation). Certainly, situations may warrant initiation of a taper, however, there can be mistakes made at the PDMP level or specific situations where an additional controlled substance was warranted in the context of individualized patient factors, thus necessitating continuation of said opioid.
Despite the updated 2022 CDC guidelines for prescribing opioid therapy for pain, there continues to be controversy and questions regarding the correct methods to use when tapering or discontinuing opioids when medically necessary. Due to the significant adverse effects associated with rapid tapering or sudden discontinuation of opioid therapy, we agree with a more frequent scheduled follow-up of 1 month.⁹
Please see our in-depth discussion on tapering for further analysis.
As stated above, it is essential to obtain patient feedback at each visit and to determine whether opioids continue to meet treatment goals. When therapy becomes less efficacious, we recommend several of the approaches taken in the updated 2022 CDC guidelines.
Similar to the 2016 guidelines, the updated recommendations suggest that clinicians weigh the risks/benefits of continued opioid medication on follow-up visit at 1 month if patients deny improvement in pain symptoms and consider alternative interventions or treatment plans at that time. Recent studies suggest that patients who do not experience pain relief from opioid therapy at 1 month are unlikely to experience pain relief with opioids after 6 months.¹⁰
The first approach we recommend is utilizing multimodal therapies for those no longer responding to single-modality therapy. Clinicians should tailor combined medications depending on patient needs, cost, convenience, and other individual factors, and attempt to line up specific mechanisms of action with the associated symptoms to best treat hypothesized pathologies. A trial of nonopioid medications with an opioid medication might provide complementary/synergistic benefits and facilitate lower dosing of individual medications.¹¹
However, clinicians must use clinical judgment when combining a multimodal approach due to potential adverse reactions and drug-drug interactions. For example, combinations of medications such as an opioid with gabapentin have been associated with increased risk of overdose.¹¹ Extreme caution is warranted with prescribing opioid medication and benzodiazepines concurrently due to studies revealing a potential near quadrupling risk for overdose and death.¹²
The 2022 guidelines caution that if opioids are continued for subacute or chronic pain, clinicians should generally avoid dosage increases when possible. If doses are increased, be wary of increasing dosage on subsequent visits above levels likely to yield diminishing returns in benefits relative to risks to patients. Providers should use clinical judgement and be aware that additional dosage increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits relative to risks.¹³ As we will describe going forward, there are inherent flaws when using morphine equivalents across the spectrum of opioids and pain types, therefore utilizing arbitrary “morphine equivalent limits” as a way to assess absolute risk, in it of itself, should be avoided overall. Morphine equivalence certainly has important utilization in specific settings, however using it to assess risk alone can be dangerous and inconsistent.
The 2022 CDC opioid prescribing guidelines recommend that clinicians carefully weigh risks and benefits when continuing opioid dosage for a patient who is already receiving higher opioid dosages. The CDC has removed dosage limits (previously greater than 50 morphine milligram equivalents per day) and allows the term “higher opioid dosage” to be based on clinical judgment.
It is imperative that the above protocols are followed, and goals continue to be re-established. We strongly recommend against abrupt discontinuation of high-dose opioid usage. Clinicians may refer to our tapering analysis for further information on the management of these cases.
Overall, we strongly support much of the content provided in the updated 2022 CDC opioid prescribing guideline for follow-up pain management visits. We commend the incorporation of a more multidisciplinary approach to those being managed with chronic opioid therapy. We are optimistic that the push for clinicians and health systems to ensure all patients have access to affordable follow-up evaluation will provide a safer path to management.
- Edlund MJ, Martin BC, Devries A, et al. Trends in use of opioids for chronic noncancer pain among individuals with mental health and substance use disorders: the TROUP study. Clin J Pain, 2010;26(1):1-8. doi:10.1097/AJP.0b013e3181b99f35
- Bartels K, Mayes LM, Dingmann C, et al. Opioid use and storage patterns by patients after hospital discharge following surgery. PLoS One. 2016;11(1):e0147972. Published 2016 Jan 29. doi:10.1371/journal.pone.0147972
- Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608-615. doi:10.1001/jamainternmed.2014.8071
- Broussard CS, Rasmussen SA, Reefhuis J, et al. Maternal treatment with opioid analgesics and risk for birth defects. Am J Obstet Gynecol. 2011;204(4). doi:10.1016/j.ajog.2010.12.039
- Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24(6):733-738. doi:10.1007/s11606-009-0981-1
- Walley A Y, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis BMJ 2013;346:f174 doi:10.1136/bmj.f174
- Cochran G, Brown J, Yu Z, et al. Validation and threshold identification of a prescription drug monitoring program clinical opioid risk metric with the WHO alcohol, smoking, and substance involvement screening test. Drug Alcohol Depend. 2021;228:109067. doi:10.1016/j.drugalcdep.2021.109067
- Lin DH, Lucas E, Murimi IB, et al. Physician attitudes and experiences with Maryland’s prescription drug monitoring program (PDMP). Addiction. 2017;112(2):311-319. doi:10.1111/add.13620
- FDA. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. April 9, 2019. Available at: www.fda.gov/drugs/drug-safety-and-availability/fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes Accessed September 2022.
- Kalso E, Simpson KH, Slappendel R, et al. Predicting long-term response to strong opioids in patients with low back pain: findings from a randomized, controlled trial of transdermal fentanyl and morphine. BMC Med. 2007;5(1):39. doi:10.1186/1741-7015-5-39
- Chou R, Hartung D, Turner J, et al. Opioid treatments for chronic pain. Comparative effectiveness review No. 229. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 20-EHC011. Rockville, MD: Agency for Healthcare Research and Quality; April 2020. DOI: 10.23970/AHRQEPCCER229.
- Park TW, Saitz R, Ganoczy D, et al. Benzodiazepine prescribing patterns and deaths from drug overdose among US veterans receiving opioid analgesics: case-cohort study. BMJ. 2015;350:h2698. Published 2015 Jun 10. doi:10.1136/bmj.h2698
- Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-1321. doi:10.1001/jama.2011.370
- Dowell D, Compton WM, Giroir BP. Patient-centered reduction or discontinuation of long-term opioid analgesics: The HHS guide for clinicians. JAMA. 2019;322(19):1855-1856.
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