CDC Guidelines on Opioid Pain Killer Use

The new CDC Guideline for Prescribing Opioids for Chronic Pain came down strongly against the use of opioids for chronic pain.

The head of the CDC, Thomas Frieden stated that in most cases the risks of opioid use outweigh the benefits and that doctor's are largely to blame for what he called the "the prescription overdose epidemic"

"The prescription overdose epidemic is doctor-driven" Frieden said, adding it can be reversed if doctors rein in their prescriptions of the painkillers.

Nearly two million Americans are either dependent on or are abusing prescription opioid pain relievers. About 40 people die each day.

The CDC estimates that 10 million Americans spend 9 billion dollars a year on opioid pain relievers, that about ten thousand people die every year from prescription drug "abuse" - most of it unintentional, and that over 400,000 people visit emergency room because of prescription opioid drug overdoses.

"We know of no other medication routinely used for a nonfatal condition that kills patients so frequently," said CDC director Thomas Frieden. "We hope to see fewer deaths from opiates. That's the bottom line. These are really dangerous medications that carry the risk of addiction and death."

He said that many opiate pain-killers are as addictive as heroin and do little to control chronic pain.

See a larger thread on this topic here.

Twelve Recommendations

In a nutshell the CDC recommends that other means of pain relief be used for chronic pain. It recommended that

• When opioids are used they should be combined with other therapies including other drugs and behavioral therapies.
• Realistic goals for pain relief should be set before pursuing opioid therapy, the risks outlined and a plan for getting off opioids, if necessary, be put in place.
• Immediate release (vs extended release) opioids should be used. The lowest effective dosage should be used.
• Opioids should be used to manage acute pain for at most days.
• Opioid effectiveness should be checked every few months.
• Before getting opioids patients should take a urine test to see of they are already taking them
• Doctors should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
• Buprenorphine or methadone in combination with behavioral therapies should be prescribed for patients with opioid use disorder.

It's clear that much work remains to assess the benefits/risks of opioid pain-killer use, when it is effective and when it is not and what alternatives are available.

Full CDC Recommendations

Determining When to Initiate or Continue Opioids for Chronic Pain

1. 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.
2. 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 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.
3. 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.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

1. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
2. 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 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.
3. 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.
4. Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 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.

Assessing Risk and Addressing Harms of Opioid Use

1. 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.
2. 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 3 months.
3. 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.
4. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
5. 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.