Update from the CDC: Practice Guidelines for Prescribing Opioids

SUMMARY:

Pain is one of the most common reasons for a patient to visit their doctor, with one study showing roughly 50% of primary care visits related to a pain complaint. Prescriptions for opioids increased over the 1990s and 2000s, peaking in 2012 and decreasing since, though there remain pockets of high opioid dispensing rates scattered throughout America. As opioid use has become more ubiquitous, the death rate from drug overdoses has also increased steadily, with a sharp rise in deaths during the COVID pandemic. In recent years federal and local governments have attempted to address these worrisome trends with improved funding for resources for the treatment of opioid use disorder, and prevention strategies such as guidelines to help clinicians who prescribe opioids. Following the publication of the 2016 CDC guidelines for prescribing opioids, there was a sharp decrease in opioid prescriptions, with the dispensing rate falling to its lowest level in 15 years. The CDC has recently announced updates to its opioid prescribing guideline and has issued 12 key recommendations and 5 guiding principles to aid in implementation.

Guiding Principles

Acute (< 1 month), subacute (1 to 3 months), and chronic pain (> 3 months) should be assessed and treated regardless of whether opioids are part of the treatment regimen
Recommendations are voluntary and are intended to be flexible with individualized patient-centered care
- Following the 2016 CDC guideline publication there were several studies that demonstrated harm to patients due to provider rigidity over prescribing opioid pain medications, including “untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior”

Use a multimodal and multidisciplinary approach to pain management including behavioral health and social support systems
Avoid misapplying the guideline beyond its intended use or implementing policies derived from the guideline that may lead to harm or untreated pain
Clinicians and health systems should be especially vigilant regarding healthcare inequities in prescribing pain medications
- Groups with highest rate of death from drug overdose: American Indian men | Alaska Native men | Black men
- In one study examining Medicare beneficiaries with disability, the annual prevalence of prescription opioid receipt was similar among Black and White patients, but Black patients received 36% fewer MME (Morphine Milligram Equivalent).

Tap Here to See MME Calculator

Note: The CDC excludes certain groups from the below recommendations, including those below the age of 18, and pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.

Key Recommendations

Initiating Opioids for Pain

Prior to prescribing any opioids
- Clinicians should review the patient’s history of opioid use via the state prescription drug monitoring program (PDMP)

Acute Pain

Nonopioid therapies are at least as effective as opioids for many common types of acute pain

Nonopioid pharmacologic and nonpharmacologic therapies should be maximized prior to initiating opiates for acute pain
Opioids for acute pain should only be given when benefits outweigh risks
Risks of opioid use and possible benefits should be discussed with patient
Acute Pain conditions where nonopioid therapy has been shown to be as effective include
- Low back pain | Neck pain | Minor MSK injuries | Minor surgeries | Kidney stones | Migraine

Nonpharmacologic therapies include
- Ice | Heat | Elevation | Rest | Immobilization | Exercise | Massage

Nonopioid Pharmacologics include
- Tylenol | NSAIDs | Menthol gel | Triptans | Muscle relaxants

Subacute and Chronic Pain

Nonopioid therapies are preferred for subacute and chronic pain
Maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate
Consider initiating opioid therapy if benefits outweigh risks
Discuss risks and benefits with patient
- Establish treatment goals | Make a plan to discontinue if benefits don’t outweigh the risks

Nonpharmacologic therapies include
- Physical therapy | Weight loss | Psychological therapy | Spinal manipulation | Low-level laser therapy | Massage | Acupuncture | Cognitive behavior therapy | Mindfulness practices

Nonopioid Pharmacologics include Topical NSAIDS | SNRIs | Tricyclics | Gabapentin | Pregabalin | Capsaicin | Lidocaine patches

NSAID Use

NSAIDs should be used at the lowest effective dose and shortest duration needed and should be used with caution, particularly in older adults and in patients with cardiovascular comorbidities, chronic renal failure, or previous gastrointestinal bleeding

Opioid Drug and Dose Selection

When starting opioids for all pain types (Acute | Subacute | Chronic), begin with immediate release formulations
- Extended release/long-acting (ER/LA) opioids should be reserved for severe, continuous pain
- Some ER/LA opioids should be reserved for opioid-tolerant patients (Methadone | Fentanyl)

Initiate the immediate release opioids at the lowest effective dosage for opioid-naïve patients
- Approximately 5 to 10 MME or a daily dosage of 20 to 30 MME/day

If opioids are continued use caution
- Carefully evaluate individual benefits and risks when considering increasing dosage
- Avoid increasing dosage above levels likely to yield limited benefits with greater risks
- Doses ≥ 50 MME/day yield diminishing returns and progressively increasing risks which should be discussed with patient and carefully considered

Once on opioid therapy, clinicians should carefully weigh benefits and risks when changing opioid dosage
Patients who are at higher risk for adverse events
- Sleep apnea | Hepatic dysfunction | CKD/ESRD | Pregnancy | Substance use disorder | >65 years | Work in Safety Critical Jobs | Mental health disorders | Prior overdose

If benefits do not outweigh risks of continued opioid therapy, optimize other therapies while working to gradually taper to lower dosages or appropriately taper and discontinue opioids
Patient agreement is vitally important for a successful taper

Reasons to taper include
- Patient request | Pain has improved and underlying cause may have resolved | Misuse | Development of comorbidities that increase risks from opioid use | Side effects diminish quality of life | Side effects impair function | Ongoing therapy has not improved pain | Overdose or serious adverse event has occurred

Tapers of approximately 10% per month or slower are likely to be better tolerated when patients have been taking opioids for longer durations (≥ 1 year)
Tapers of 10% per week may be tolerated for those on opioids for shorter durations (weeks to months)
Do not abruptly discontinue or rapidly reduce to low doses unless there are indications of a life-threatening issue such as concern for impending overdose (e.g., confusion, sedation, slurred speech)
- Risks of abrupt withdrawal of opiates include: Acute withdrawal symptoms | Exacerbation of pain | Serious psychological distress | Suicidal ideation

Duration and Follow Up

Acute Pain

Prescriptions dispensed for acute pain should contain only enough opioids for the expected duration of pain severe enough to require opioids
- For many causes of acute pain an initial opioid prescription of 4 to 7 days’ duration is sufficient
- Reevaluate and rule out other causes of pain if patient continues to need opioids for >2 weeks for acute pain

Subacute and Chronic Pain

Reevaluate benefits and risks with patients within 1 to 4 weeks of starting or adjusting dosage of opioid therapy
Interval for follow up after initiating or adjusting opioids should be shorter if
- Receiving > 50 MME/day | Starting methadone | Starting ER/LA opioids

For patients on long term opioids follow up is recommended at least every 3 months

Risk Assessment

Periodically during follow up
- Rediscuss risks of opioids with patient | Check PDMP to review dosages of opioids received | Discuss strategies to mitigate risk | Offer Naloxone (FDA approved OTC Naloxone spray March 2023)

Consider using toxicology testing annually “to assess for prescribed opioids and other prescription and nonprescription controlled substances that increase risk for overdose when combined with opioids”
- Results should be used in a non-punitive manner and testing discussed prior to being undertaken with the patient

Use caution when prescribing opioid pain medication and benzodiazepines together
- Consider tapering off benzos prior to initiating opioids

Offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder
Opioid use disorder definition
- Defined by the DSM-5 (see ‘Primary Sources – Learn More’ below)