How CDC Opioid Prescribing Guidelines Affect PCPs

ORLANDO — Due to rapidly increasing rates of opioid dependency and overdose, the Centers for Disease Control and Prevention (CDC) released the CDC Guideline for Prescribing Opioids for Chronic Pain in 2016, to be used in primary care settings.¹

In a presentation at the 2017 annual meeting of the American Academy of Pain Medicine (AAPM), Bill McCarberg, MD, an adjunct assistant clinical professor at the University of San Diego, reviewed each component of the guideline and explored how it may benefit or impede the ability of a primary care physician (PCP) to provide effective pain management.²

The guideline includes 12 recommendations grouped into 3 areas as follows.

Determining when to initiate or continue opioids for chronic pain.

• The preferred treatment approaches for chronic pain are nonpharmacologic therapies such as cognitive behavioral therapy (CBT), joint injections, and physical therapy, as well as nonopioid pharmacologic therapies including nonsteroid anti-inflammatory drugs (NSAIDs) and certain antidepressants and anticonvulsants. Opioids should be considered only when the anticipated benefits in pain and functional improvement outweigh the potential risks.
• Physicians should establish realistic treatment goals with patients regarding pain and function prior to initiating opioid therapy, and treatment should continue only in the presence of clinically meaningful improvement that outweighs safety risks.
• Physicians should discuss known risks and benefits of opioids, as well as patient responsibilities in their care management, prior to initiating their use and periodically during treatment.

Opioid selection, dosage, duration, follow-up, and discontinuation.

• To reduce the risk of overdose, physicians should prescribe immediate-release opioids vs extended release/long-acting (ER/LA) opioids (methadone, transdermal fentanyl, and ER versions of oxycodone, hydrocodone, etc) when initiating opioid therapy.
• The lowest effective dose of opioid should be prescribed when treatment is initiated, with a goal of <50 morphine milligram equivalents (MME) per day and generally not to exceed 90 MME per day.
• Because acute pain treatment often leads to long-term opioid use, the guideline recommends that clinicians prescribe the lowest effective dose of immediate-release opioids in such cases when warranted, for a duration of 3 days or less and no more than 7 days in most cases.
• Benefits and harms of opioid therapy should be assessed within 1 to 4 weeks of initiating treatment or escalating the dose and at least every 3 months thereafter. Opioids should be tapered and/or discontinued if it is determined that benefits do not outweigh harms. 

Assessing risk and addressing harms of opioid use.

• Prior to starting and periodically during opioid treatment, the patient’s risk factors for opioid-related harms should be evaluated. If such risk factors – for example, a history of substance use disorder or concurrent benzodiazepine use – are identified, risk mitigation strategies should be integrated into the treatment plan.
• At the start of opioid therapy and at regular intervals thereafter, physicians should use state prescription drug monitoring program (PDMP) data to review the patient’s prescription history for any dosages or drug combinations that may increase overdose risk.
• To assess for prescribed opioids and other prescription and illicit drugs the patient may be taking, physicians should consider urine drug screening before and during opioid treatment.
• When possible, clinicians should not prescribe opioids and benzodiazepines concurrently, as both cause central nervous system depression and increase the risk of fatal overdose when used together.
• If it is determined that a patient has opioid use disorder, the physician should offer or refer the patient to evidence-based treatment such as medication-assisted treatment combined with behavioral therapies.

In addition to monitoring risks and benefits and addressing these with patients, Dr McCarberg advises clinicians to establish relationships with pain specialists for consultation and referral, and to become familiar with state medical board policies regarding PDMP, urine screening, dosage limits, and visit frequency.

Summary and Clinical Applicability

This AAPM 2017 presentation covers the 2016 CDC guideline on opioid prescribing for PCPs and explores potential benefits and hindrances associated with the recommendations. 

Disclosures

Dr McCarberg reports that he is an advisor to, and has stock holdings in, numerous pharmaceutical and biotechnology companies.

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References

1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain–United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. doi: http://dx.doi.org/10.15585/mmwr.rr6501e1
2. McCarberg B. How opioid prescribing guidelines may affect (help or hinder) a primary care physician’s ability to provide pain management. Presented at: the American Academy of Pain Medicine 33rd Annual Meeting; March 16-19, 2017; Orlando, Florida.