Not Too Much and Not Too Long: Appropriate Use of Opiates for Pain Management
In March 2016, the US Centers for Disease Control and Prevention (CDC) released a guideline for prescribing opioids for chronic pain. The most important points for primary care providers treating acute pain severe enough to require opioids are to prescribe the lowest effective dose of immediate-release opioids and to prescribe a quantity no greater than what is necessary. Three days or less will often be sufficient; more than seven days will rarely be needed.
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. The CDC guideline is intended to apply to patients aged ≥18 years with chronic pain outside of palliative and end-of-life care. Key points from the guideline are as follows:
Determining When to Initiate or Continue Opioids for Chronic Pain
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. 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.
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. When opioids are started, clinicians should prescribe the lowest effective dosage. 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.
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.
Assessing Risk and Addressing Harms of Opioid Use
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. 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. Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65:1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1
Harold J. Farber, MD, MSPH
Associate Medical Director, Texas Children’s Health Plan