Opioids are commonly prescribed for chronic pain, and in fact approximately 20% of patients presenting with noncancer pain symptoms will receive an opioid prescription in a physician’s office. Opioid prescriptions increased 7% per capita between 2007 and 2012. Along with this increase in prescriptions has been a proportional increase in opioid-related deaths.
The Centers for Disease Control and Prevention guidelines provides recommendations aimed at primary care clinicians for prescribing opioid medications for chronic pain in the outpatient setting. Chronic pain is defined as pain that lasts longer than 3 months, which may be a result of underlying medical disease, injury, medical treatment, or unknown causes. The target population for the guidelines are patients over 18 years of age with chronic noncancer pain. The guidelines are not intended for the clinical care of patients at the end of life, palliative care, or active cancer patients. Special populations that are addressed in the guidelines include older adults, pregnant women, and patients with a history of substance use disorder.
After a detailed review of the evidence, the CDC summarized 12 recommendations for physicians when prescribing opioids for chronic pain, outlined below, and divided them into three sections. All of the recommendations are category A, meaning they apply to most patients. The exception is recommendation No. 10, as it pertains to urine drug testing, which is a category B recommendation, meaning that different choices may be appropriate for some patients.
Determining when to initiate or continue opioids for chronic pain
1. Nonpharmacologic treatment and nonopioid pharmacologic treatments are preferred for chronic pain. Opioids are not a first-line option and should be combined with nonpharmacologic therapy and nonopioid medications if appropriate.
2. Treatment goals should be established with all patients when initiating therapy. Continuation of opioid treatment should occur only if improvement in pain and/or function continues to outweigh the risks of the treatment.
3. Discussion of the risks and realistic benefits of opioid therapy should occur with patients at initiation and during the treatment course.
Opioid selection, dosage, duration, and discontinuation
4. When starting opioid therapy for chronic pain immediate-release opioids should be used initially. Extended-release/long-acting opioids are associated with a higher risk of overdose when treatment is initiated with these; therefore, extended-release/long-acting opioids should be used only for patients with severe, continuous pain and only after a patient has received immediate-release opioids for at least 1 week.
5. Opioids should be prescribed at the lowest effective dose. Avoid dosages greater than 90-mg morphine equivalents per day, and exercise caution at doses greater than 50-mg morphine equivalents per day.
6. Because most chronic pain is initially treated as acute pain, when treating acute pain be sure to use the lowest dose, and prescribe only the amount anticipated to be required for the acute injury/complaint. Prescriptions of longer than 7 days for acute pain are usually not necessary.
7. Evaluate the benefits and harms of opioid prescription within 1-4 weeks of initiation or dose escalation. Always consider tapering or discontinuation if goals are not being met.
8. Evaluate risk factors for opioid-related harms both when initiating medications and periodically during treatment. Risk factors include a history of substance use disorder, high opioid doses, or benzodiazepine use.
Assessing risk and addressing harms of opioid use
9. Review patients’ prescription drug monitoring program to help determine the risk for overdose. Intervals of review may range from when each prescription is given to every 3 months.
10. Utilize urine drug screening when initiating medication and periodically (at least annually). Discuss all unexpected results with the lab, patient, and possibly toxicologist. Repeatedly negative urine drug screens indicate the patient is not taking a prescribed opioid, and therefore medication can be discontinued without a taper.
11. Avoid prescribing a benzodiazepine and opioids concurrently because of a higher risk of fatal overdose.
12. Arrange treatment for patients with opioid-use disorder such as referral to a medication-assisted treatment center for buprenorphine or methadone treatment.
Special populations
The CDC addressed several special populations for which special care when initiating or titrating opioid therapy should be taken:
• Patients with sleep-disordered breathing. Any patient with moderate-to-severe sleep-disordered breathing, including sleep apnea, should avoid opioids if possible; if opioids can’t be avoided, slow titration and lower starting doses should be used.
• Pregnant women and reproductive age women. Use in pregnancy can lead to additional risks for both mother and fetus; therefore, initiation of opioids for chronic pain in any reproductive age woman should include this information so a proper joint decision may be made between patient and clinician. The risks include preterm delivery, birth defects, stillbirth, poor fetal growth, and neonatal abstinence syndrome.
• Patients older than 65. Because of decreasing renal function, this population is at risk for the accumulation of opioids and may be unable to tolerate nonopioid pharmacologic therapy such as NSAIDs as a result of comorbidities. When opioids are necessary, the recommendations indicate a need for fall risk assessment, monitoring for cognitive impairment, and an appropriate bowel regimen.
• Patients with mental health conditions. These patients pose a high risk for overdose both because of polypharmacy, specifically benzodiazepine use, and mental instability. Make sure patients are being optimally treated for their mental health disorders, and when possible consider the use of tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for additional pain relief.
• Patients with substance use disorders. Those who use illicit substances contribute to a significant proportion of deaths related to opioid use. However, the previously recommended risk assessment tools were found to be inaccurate and should not provide clinicians with a sense of security when prescribing to this patient population. In addition, consulting a substance use disorder specialist and/or pain specialist may be best for this population.
The bottom line
Opioid use has been increasing steadily in the United States with a proportional increase in opioid overdoses. The CDC guidelines present a strategy to prescribing opioids that emphasizes caution, careful decision making, and monitoring when prescribing opioids in order to best control pain while mitigating the risks of opioid use disorder and overdose.
Reference
CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-50.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is currently a third-year resident and chief resident in the family medicine program at Abington Memorial Hospital.
