The Centers for Disease Control and Prevention (CDC) issued new voluntary guidelines this week for prescribing opioid medications for chronic pain, excluding cancer, palliative, and end-of-life care. The CDC Guideline for Prescribing Opioids for Chronic Pain, United States, 2016 will help primary care providers ensure the safest and most effective treatment for their patients.
In related news, 41 physicians submitted a petition to FDA, asking the agency add a black box warning on all medications in the opioid and benzodiazepine classes. The label addition would warn prescribers and patients about a reduced margin of safety and increased risk of fatal overdose when these classes of medication are used together.
“The United States is currently experiencing an epidemic of prescription opioid misuse and overdose. Increased prescribing and sales of opioids—a quadrupling since 1999— helped create and fuel this epidemic,” the CDC said in a statement.
The American Pharmacists’ Association (APhA) praised the CDC recommendations, saying they are “consistent with other public and private efforts that aim to curb prescription drug abuse while attempting to balance patient access to medically necessary treatment,” Jenna Ventresca, JD, associate director of health policy for APhA said.
Among the CDC’s 12 recommendations for opioid prescribing are:
1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
2. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
3. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids, which include methadone, transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone, and morphine. The clinical evidence review found a fair-quality study showing a higher risk for overdose among patients initiating treatment with ER/LA opioids than among those initiating treatment with immediate-release opioids.
4. When opioids are started, clinicians should prescribe the lowest effective dosage. In addition, clinicians should use caution when prescribing opioids at any dosage and should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine mg equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
5. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. “If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids,” CDC wrote in the recommendations.
CDC also developed user-friendly materials to assist providers with implementing the recommendations, including a decision checklist.
Read more: Top 4 new prescription opioid abuse facts