New CDC Guidelines for Prescribing Opioids for Patients with Chronic Pain

Lee TH., JAMA 2016 Mar 15;

Twelve recommendations focus on opioid use for chronic pain not related to cancer or end-of-life care.

Background

About 20,000 people died from opioid overdoses in 2014; 3% to 4% of the U.S. population receive prescriptions for long-term opioid therapy. The CDC has released what is considered to be the first federal clinical guideline for use of opioids in adults with chronic pain (duration, >3 months) not related to cancer or end-of-life care. The guideline is based on an update of a 2014 systematic review; at that time, no studies had evaluated benefits of opioid use for ≥1 year, but substantial risks of addiction, overdose, and death from long-term use had been documented.

Key Recommendations

The guideline comprises 12 recommendations:

• Nonpharmacological (e.g. exercise, cognitive behavioral therapy) and nonopioid pharmacological therapies are preferred for managing chronic pain.
• Opioids should be prescribed only after setting clear treatment goals focused on both improving function and decreasing pain.
• Risks of opioid use for chronic pain should be discussed explicitly.
• Immediate-release opioids are strongly, if not exclusively, preferred over extended-release or long-acting opioids; methadone is not the preferred choice for a long-acting opioid and should only be used by clinicians with special expertise.
• Clinicians should initiate opioids at the lowest effective dose. When dosage must be escalated, doses should be limited to 50 MMEs (morphine mg equivalents; 50 MMEs=50 mg of hydrocodone or 33 mg of oxycodone) daily in most circumstances, and 90 MMEs daily without special justification.
• Opioid prescriptions for acute pain should be limited to 3 days in most circumstances.
• Benefits and harms of opioid therapy should be reviewed within 1 to 4 weeks of starting therapy or increasing dose and regularly thereafter.
• Opioid use should be avoided in patients with sleep-disordered breathing or with renal or hepatic insufficiency, in those who are pregnant, and in elders (age, ≥65). Clinicians should consider making naloxone available for patients at high risk of overdose.
• Data from state prescription monitoring programs should be reviewed at the initiation of opioid therapy and periodically thereafter.
• Clinicians should consider using urine drug testing at initiation of opioid therapy and periodically thereafter.
• Concomitant benzodiazepine use increases risk for overdose and should be avoided.
• Clinicians should monitor patients for opioid-use disorder (addiction or excessive use) and arrange for evidence-based treatment as needed.

Comment This guideline was portrayed as being directed specifically to primary care clinicians, but it should be directed toward any clinician who provides chronic pain care to adults who are not receiving palliative or cancer care. Clinicians can invoke this guideline during discussions with patients who insist on progressive opioid dose escalation without good justification. An editorialist describes his personal practices in prescribing opioids for chronic pain, including using only immediate-release opioids, never exceeding the 50 MME threshold, prescribing only 1 month of medication at a time, never authorizing refills, deemphasizing pain scores and assessments, and focusing on daily function.