On March 15, 2016 the CDC released their first ever “CDC Guidelines for Prescribing Opioids for Chronic Pain – United States 2016”. Please see the link below for the complete text:
Embedded in the above Guidelines are two(2) additional links to serve as a checklist for physicians in implementing the recommendations:
In summary, the categorization of recommendations (12 in total) was based on the following assessment:
- No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized trials ≤6 weeks in duration).
- Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury).
- Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm.
The clinical evidence review found insufficient evidence to determine long-term benefits of opioid therapy for chronic pain and found an increased risk for serious harms related to long-term opioid therapy that appears to be dose-dependent.
Pain lasting longer than 3 months or past the time of normal tissue healing (which could be substantially shorter than 3 months, depending on the condition) is generally no longer considered acute.
The CDC grouped the 12 recommendations into three areas for 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 opiod use.
Determining when to initiate or continue opioids for chronic pain
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients
- Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
- When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
- When opioids are started, clinicians should prescribe the lowest effective dosage.
- Clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
- Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy
Assessing Risk and Addressing Harms of Opioid Use
- Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms.
- Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.
- When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
- Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
- Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
While these recommendations by the CDC are non-binding and physicians are not legally obligated to follow them, hopefully this will influence prescribing protocols going forward. What remains to be seen is if and when the AMA will respond to or implement these guidelines, and if/when CMS may incorporate these guidelines into the WCMSA Reference Guide.
There is certain to be much discussion/debate about these guidelines in the coming months, and Axiom will keep you informed as information becomes available.