Wednesday, March 16, 2016

CDC Releases Guideline for Prescribing Opioids for Chronic Pain

The Centers for Disease Control and Prevention (CDC) has issued a guideline for clinicians who are prescribing opioids for chronic pain that is not associated with cancer, palliative care, or end-of-life care. The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment options for pain management, improve patient outcomes, and reduce the number of people who develop opioid use disorder, overdose, or experience other adverse events related to these drugs.

“The new guideline really points out the dangers of the liberal prescribing of opioids,” said Petros Levounis, M.D, M.A., an addiction expert and chair of the Department of Psychiatry at Rutgers New Jersey Medical School. “Addiction psychiatry has been at the forefront of the fight against the opioid epidemic for at least 10 years now, from preventing the initiation of opioids to supporting the use of treatment for opioid addiction with FDA-approved medicines such as buprenorphine,” he told Psychiatric News.

The guideline includes 12 recommendations, which address when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use: 

Nonpharmacologic (e.g., physical therapy, cognitive-behavioral therapy) and non-opioid therapies (e.g., NSAIDs, acetaminophen) are preferred for chronic pain. The CDC recommends that clinicians should consider opioid therapy only if expected benefits outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and non-opioid pharmacologic therapy, as appropriate. 

When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose. The CDC recommends that clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. 

Health care professionals should always exercise caution when prescribing opioids and monitor all patients closely. Because mental illness can affect pain and function in patients with chronic pain, the CDC recommends that clinicians use validated instruments to assess for anxiety, posttraumatic stress disorder, and/or depression that might help clinicians improve treatment outcomes. 

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. For patients with problematic opioid use that does not meet criteria for opioid use disorder, the CDC recommends clinicians should offer to taper and discontinue opioids.

“Although some of the items in the guideline are not supported by as much scientific evidence as we would like to appropriately make these recommendations [such as dosing], at least this is a good start in helping to address prescription practices concerning opioids,” Levounis added.

For related information on the FDA’s Opioid Action Plan, see the Psychiatric News article “Robert Califf, M.D., Confirmed as FDA Commissioner.”

(Image: Courtsey of CDC)