The Centers for Disease Control & Prevention (CDC) has come out with new guidelines for physicians to follow in prescribing opioid therapy for chronic pain. The CDC has chronic pain defined as “pain exceeding three or more months past the time it normally takes an injury to heal.” These new guidelines are meant to help healthcare professionals be more astute in their prescribing of opioid therapy for chronic pain in adults being seen in outpatient settings. These guidelines are not meant for managing the pain that cancer patients suffer while receiving chemotherapy, or patients in palliative and/or end-of-life care.
The guidelines set forth by the CDC have 12 basic recommendations covering three domains:
Domain 1: Deciding When to Start or Continue Opioid Medication for Chronic Pain
- The preferred treatments for chronic pain are nonpharmacologic and nonopioid. Opioid therapy should only be considered if the benefits expected for pain and function would outweigh the risks for the patient. If the physician prescribes opioids, he/she should combine them with nonpharmacologic as well as nonopioid pharmacologic treatments.
- Prescribers should always set down treatment goals before initiating opioid therapy for chronic pain. These goals must be realistic in terms of treating pain and function while considering how treatment would be discontinued in the event that the benefits don’t outweigh the risks.
- Before starting opioid therapy and intermittently during treatment, prescribers should talk to their patients about the known risks and what opioid medication can realistically offer in terms of benefits. While discussing this, consumers must be made aware of their own responsibility for managing treatment.
Domain 2: Selecting the Opioid Medication, the Dosage, Duration, and Follow-Up, as well as Timeline for Discontinuation
- When beginning opioid therapy for chronic pain, physicians should issue a prescription for immediate-release opioids, not extended-release or long-acting opioids (ER/LA).
- In starting opioids, physicians should prescribe the very lowest effective dose.
- Long-term use of opioid medication often starts with treating acute pain. If opioid medication is being used to treat acute pain, physicians should prescribe the very lowest effective dose for immediate-release opioid medication. They should only prescribe the quantity needed for the anticipated duration of pain so severe that only opioids can treat it. No more than three days should be sufficient and more than a week’s time would rarely be required.
- Physicians should assess the benefits and possible harms with patients within one to four weeks of initiating opioid therapy for chronic pain or of increasing the dosage. Prescribers should assess the benefits and possible harms with patients every three months if not more often.
Domain 3: Evaluating Risks & Addressing the Harms of Opioid Medication
- Before starting opioid treatment and intermittently during continuation, physicians should assess the risk factors of harms related to opioid use.
- Prescribers should look at the patient’s history of using controlled substances by reviewing the information on PDMP, their State’s Prescription Drug Monitoring Program. This data will show if the patient is getting opioid medication or dangerous combinations of medications that would put him/her at a high risk of overdosing.
- When prescribing opioid therapy for chronic pain, physicians should have the patient take a urine drug test before beginning opioid treatment. This should be done annually at minimum to assess for all prescribed medications and any other controlled prescription medications and even the illicit use of drugs.
- Physicians should avoid issuing prescriptions for opioid pain medications at the same time the patient is taking benzodiazepines whenever possible.
- Physicians should arrange for or offer evidence-based treatment, which usually involves medication-assisted therapy with methadone or buprenorphine combined with behavioral therapy to treat chronic pain in patients diagnosed with an opioid use disorder.
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