As part of the U.S. government’s urgent response to the epidemic of overdose deaths, on March 15, 2016, the CDC issued new recommendations 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.
The United States is currently experiencing an epidemic of prescription opioid overdose. Increased prescribing and sales of opioids—a quadrupling since 1999— helped create and fuel this epidemic.
“More than 40 Americans die each day from prescription opioid overdoses, we must act now,” said CDC Director Tom Frieden, M.D., M.P.H. “Overprescribing opioids—largely for chronic pain—is a key driver of America’s drug-overdose epidemic. The guideline will give physicians and patients the information they need to make more informed decisions about treatment.”
Opioids are commonly prescribed for pain. An estimated 20% of patients presenting to physician offices with noncancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription. In 2012, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills. Opioid prescriptions per capita increased 7.3% from 2007 to 2012, with opioid prescribing rates increasing more for family practice, general practice, and internal medicine compared with other specialties. Rates of opioid prescribing vary greatly across states in ways that cannot be explained by the underlying health status of the population, highlighting the lack of consensus among clinicians on how to use opioid pain medication.
The guideline provides recommendations on the use of opioids in treating chronic pain (that is, pain lasting longer than three months or past the time of normal tissue healing). Prevention, assessment, and treatment of chronic pain are challenges for health providers and systems. Pain might go unrecognized, and patients, particularly members of racial and ethnic minority groups, women, the elderly, persons with cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment. Patients can experience persistent pain that is not well controlled. There are clinical, psychological, and social consequences associated with chronic pain including limitations in complex activities, lost work productivity, reduced quality of life, and stigma, emphasizing the importance of appropriate and compassionate patient care. Patients should receive appropriate pain treatment based on a careful consideration of the benefits and risks of treatment options. The recommendations in the guideline are voluntary and are for primary care providers—who account for prescribing nearly half of all opioid prescriptions—treating adult patients for chronic pain in outpatient settings. It is not intended for guiding treatment of patients in active cancer treatment, palliative care, or end-of-life care.
While prescription opioids can be part of pain management, they have serious risks. The new guideline aims to improve the safety of prescribing and curtail the harms associated with opioid use, including opioid use disorder and overdose. The guideline also focuses on increasing the use of other effective treatments available for chronic pain, such as nonopioid medications or non-pharmacologic therapies.
By using the guideline, primary care physicians can determine if and when to start opioids to treat chronic pain. The guideline also offers specific information on medication selection, dosage, duration, and when and how to reassess progress and discontinue medication if needed. Using this guideline, providers and patients can work together to assess the benefits and risks of opioid use.
Among the 12 recommendations in the guidelines, three principles are key to improving patient care:
- Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
- When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
- Providers should always exercise caution when prescribing opioids and monitor all patients closely.
“Doctors want to help patients in pain and are worried about opioid misuse and addiction,” said Debra Houry, M.D., M.P.H., director of the CDC’s National Center for Injury Prevention and Control. “This guideline will help equip them with the knowledge and guidance needed to talk with their patients about how to manage pain in the safest, most effective manner.”
The 12 recommendations in the guidelines are:
- 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.
- 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.
- Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
- 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 use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
- Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, 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 one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three 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.
- Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
- 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. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.
- 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. Both cause central nervous system depression and can decrease respiratory drive.
- 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.
The CDC will continue to work with states, communities, and prescribers to prevent opioid misuse and overdose by tracking and monitoring the epidemic and helping states scale up effective prevention and treatment programs. It also continues to improve patient safety by equipping health care providers with data, tools, and guidance so they can make informed treatment decisions.
See the CDC Announcement
See the CDC Report
See also Medical Law Perspectives, January 2014 Report: Prescription Painkillers: Risks for Patients, Pharmacists, and Physicians
See also Medical Law Perspectives, May 2013 Report: Drugs, Dosage, and Damage: Physician Liability for Prescribing or Administering Medication
See the Medical Law Perspectives February 16, 2015, Blog: Pharmacy Owes Duty To Patient Not To Fill Excessive Prescriptions for Opioids
See the Medical Law Perspectives October 8, 2014, Blog: Opioid Pain Pill Abusers Switch to Heroin; Heroin Overdose Deaths Double