The CDC Releases New Clinical Guidelines for Opioid Use

There is no denying that the opioid addiction and overdose problem in the United States has become a significant health concern. According to the CDC, between 1999 and 2013, the amount of prescription painkillers prescribed and sold in the United States nearly quadrupled, and overdose and addiction rates have increased accordingly.

Consider these statistics:

• In 2012, healthcare providers wrote 259 million prescriptions for opioid pain killers. That is enough for every adult in America to have a bottle of pills.
• In 2013, nearly two million Americans aged 12 and older either abused or became addicted to an opioid pain reliever.
• In 2013, more than 16,000 Americans died from an opioid drug overdose. That is four times the number that died in 1999.

In an effort to alleviate the overuse of opioid drugs as a pharmaceutical treatment for pain, and to stem the growing number of addictions and drug-related deaths that result from their use, the CDC published Draft Guidelines for Prescribing Opioids for Chronic Pain in December of 2015. Since then, these guidelines have been heavily discussed by healthcare providers and patients alike. Furthermore, many physicians nationwide have adopted these recommendations as part of their treatment plans.

Though this draft may still need a bit of tweaking, it is an excellent start at providing physicians with useful guidelines to prevent the overuse of opioids. Dr. George Lundberg of Medscape provided a good analysis and breakdown of the guidelines in a video post, which can be found here.  

Some highlights of Dr. Lundberg’s assessment are as follows:

The CDC has issued recommendations for opioid use in the following categories:

• Determining when to initiate or continue use of opioids in the treatment of chronic pain
• Deciding which opioids to prescribe as well as their duration, dosage and discontinuation
• Assessing risks associated with opioid use

The CDC’s recommended guidelines are as follows:

Determining When to Initiate or Continue Opioid Use for Chronic Pain

• Physicians should consider non-pharmaceutical treatments for chronic pain as a starting point. Opioids should only be prescribed in instances where the benefits for both pain and function are expected to outweigh the risks associated with these drugs.
• Before prescribing opioids for chronic pain, physicians should establish realistic treatment goals with their patients. Physicians should also consider how drug therapy will be discontinued if it is unsuccessful at helping the patient manage their pain.
• Physicians should discuss the known risks of opioid use as well as the realistic benefits of these drugs with their patients before starting them on opioid therapy for their pain. The discussion should be repeated periodically throughout the therapeutic period.

Deciding Which Opioids to Prescribe as well as their Duration, Dosage and Discontinuation

• When beginning opioid therapy, physicians should prescribe immediate release, rather than extended-release, pharmaceuticals.
• Start with the lowest effective dose. Increase dosages, if needed, slowly and with caution. It is best to keep patients on the lowest effective dose possible.
• Physicians should not prescribe more drugs than are needed to effectively treat the pain. Three days or fewer is usually sufficient to treat acute, non-traumatic pain that is not related to surgery.
• Physicians should discuss and evaluate benefits and risks of opioid use within one to four weeks of starting opioid therapy and again at least every three months for long-term therapeutic use. If it is determined that the risks are outweighing the benefits, physicians should work with patients to reduce dosages until the therapy is fully discontinued.

Assessing the Risks Associated with Opioid Use

• For patients with risk factors for opioid overdose, such as a history of overdose, history of substance abuse, or the need for high dosages, physicians should try offering naloxone as a first step and should mitigate risks by  incorporating strategies in the management plan.
• Prior to prescribing opioids, physicians should review the patient’s history of controlled substance prescriptions by using their state prescription drug monitoring program (PDMP) to ensure that the patient is not receiving dangerous combinations that put them at risk of overdose. This data should be reviewed again at least every three months.
• Before starting opioid drug pain therapy, physicians should use urine drug testing to ensure that these therapies are not being mixed with other controlled prescription drugs or illegal drugs.
• Whenever possible, physicians should avoid prescribing opioids to patients who are also taking benzodiazepines.
• For patients with an opioid use disorder, physicians should offer or arrange evidence-based treatment, such as with buprenorphine or methadone, as well as behavioral therapies.

You can learn more by watching the full video by Dr. Lundberg or by reading the accompanying article at Medscape:  CDC Guidelines for Opioid Use.  Or, if you are looking for more in-depth information about each of these guidelines, including reading the research behind each recommendation, by downloading a full copy of the CDC’s draft recommendations here.