CDC updates clinical guidance on prescribing opioids for pain

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The CDC has released updated and expanded clinical practice guidance on prescribing opioids to patients with short- and long-term pain.

The guidance, which was first proposed in February, replaces the agency’s 2016 recommendations.

Pill bottle knocked over
The CDC has released updated clinical practice guidance on prescribing opioid treatment for pain, including categories such as acute pain and subacute pain.

“Patients with pain should receive compassionate, safe and effective pain care. We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life,”Christopher M. Jones, PharmD, DrPH, MPH, acting director of CDC’s National Center for Injury Prevention and Control, said in a press release.

According to CDC data, of more than 91,000 drug overdose deaths that occurred in the U.S. in 2020, 74.8% (n = 68,630) involved an opioid. About 10,000 of these deaths were attributed to prescription opioids.

The updated guidance includes 12 recommendations that address whether to initiate opioid therapy for pain, selecting opioids and dosages, determining the duration of treatment and assessing the risks and benefits. The guidelines advise clinicians to:

  • maximize nonpharmacologic and nonopioid pharmacologic therapies as warranted for specific situations and patients, only consider opioid treatment for acute pain if the benefits outweigh the risks, and discuss the risks and benefits with the patient beforehand;
  • understand that nonopioid therapies are preferred for subacute and chronic pain, work with patients to establish treatment goals and consider how opioid treatment will be discontinued if the risks outweigh the benefits;
  • prescribe immediate-release opioids instead of extended-release and long-acting opioids when starting opioid therapy for acute, subacute or chronic pain;
  • prescribe the lowest effective dosage of opioid therapy for opioid-naive patients with acute, subacute or chronic pain, use caution when continuing for subacute and chronic pain and avoid increasing dosage levels that are “likely to yield diminishing returns in benefits relative to risks”;
  • weigh the risks and benefits when changing prescription dosages for patients who are already on opioid therapy, while utilizing other treatments and tapering patients off opioid therapy if the risks outweigh the benefits;
  • use no greater quantity than needed for the expected duration of severe pain when using opioid therapy for acute pain;
  • evaluate the risks and benefits within 1 to 4 weeks of starting opioid therapy for subacute or chronic pain or of dose escalation;
  • evaluate the risks for opioid-related harms and discuss harms with patients before starting therapy and periodically throughout the continuation, while working with patients on management plan strategies to mitigate risks;
  • review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the opioid doses or combinations puts them at high risk for overdose before starting them on opioid therapy;
  • consider the benefits and risks of toxicology testing to assess prescribed medications as well as other prescribed and nonprescribed controlled substances;
  • use caution when prescribing opioid pain medication and benzodiazepines concurrently, and consider whether the benefits outweigh the risks when prescribing opioids with other central nervous system depressants; and
  • offer treatments with evidence-based medications for opioid use disorder, while avoiding detoxification due to increased risks for resuming drug use, overdose and overdose death.

The CDC noted that these recommendations “should not be used as an inflexible, one-size-fits-all policy or law,” but are instead voluntary and offer flexibility to patients and clinicians.

In a telebriefing, Jones touched down on several key differences between the 2016 and 2022 guidance that reflect “the expanded scope of the available scientific evidence.”

“While the 2016 guideline focused almost exclusively on chronic pain, the guideline released today also includes recommendations for treating acute and subacute pain,” he said.

Jones said it was particularly important that the guidance addressed these categories of pains, citing previous research that has shown opioid therapy is initiated during the subacute pain timeframe.

The guidance was also expanded from a focus on clinicians in a primary care setting to a broader range of providers and specialties, and it contains new information on both tapering opioid treatment and the use of nonopioid medications and treatments for pain.

“We’ve also expanded the evidence base around the use of opioid pain medications and other pain treatments in certain groups, like older adults and pregnant people, and in people with conditions posing special risks, such as those with a history of substance use disorder,” Jones said.

He added that the updated guidance also specifies which recommendations apply to patients being considered for opioid therapy, “versus those who have been receiving opioids as part of ongoing care.”

Responding to media comments, Jones discussed the CDC’s efforts to ensure the appropriate use of the updated guidance, particularly since the 2016 guidance was “misimplemented” by clinicians, putting patients at risk. According to a paper published by CDC researchers in 2019, many clinicians inappropriately applied the 2016 guidance to patients receiving cancer treatment, those experiencing acute sickle cell crises or post-surgical pain, and those receiving medication-assisted treatment for opioid use disorder. In addition, many clinicians abruptly discontinued or de-escalated opioid doses, which Jones said could cause “very real harms,” including mental health crises, suicidal ideation or behavior and psychological distress. Abrupt discontinuation or de-escalation could also lead some patients to seek out opioids through illicit markets “in order to stave off withdrawal or to supplement if they are at too low of a dose,” he said.

Jones stated that the CDC will look out for practices and policies that are inconsistent with the updated guidance and use them as an “educational opportunity.”

“We’ll be monitoring and engaging with clinical partners in patient organizations to also raise awareness for where those circumstances may occur,” he said.

References:

Perspective

Lewis Nelson, MD

The CDC appropriately codified many of the lessons learned in the years following the release of the first guideline, such as avoiding abrupt discontinuation of opioids. They also broadened the audience that will benefit from the recommendations from primary care to essentially everyone, including pain medicine practitioners.

The new guidelines are being released into a very different medical landscape than those from 2016. New legislation and regulations, cultural changes in our attitudes towards opioids and verdicts against pharma, distributors and others, and the illicit fentanyl epidemic, have dramatically altered how opioids are used for pain.

The new recommendations provide additional focus on the importance of properly managing patients with acute pain to mitigate the risk of developing long-term opioid use and opioid use disorder. They maintain their stance that chronic opioid use is generally ineffective and potentially dangerous. In general, the guidelines are very useful, particularly when one reads the supporting pages of material and not just the 12 bullet points.

One of the dissatisfying aspects of the new guidelines is the frequent use of the phrase “if benefits do not outweigh risks” and its variations. This concept is somewhat subjective and ripe for aberrancy in implementation.

An important and relevant recent change is the Ruan v. United States ruling by the Supreme Court that basically says that if a prescriber believes they are acting in the patient’s best interest, even overt overprescribing can be considered legitimate. This opens the potential for perverse prescribing since a firm understanding of the benefit and risk for any patient is largely undefinable and subject to manipulation.

Lewis Nelson, MD

Healio Primary Care Peer Perspective Board Member
Professor and chair, department of emergency medicine
Chief, division of medical toxicology at Rutgers New Jersey Medical School

Perspective

Anita Gupta, DO, PharmD, MPP

The CDC showed that during the 12-month period ending in April 2021, more than 100,000 people died in the U.S. of drug overdoses, including more than 75,000 people whose deaths involved opioids. Opioids, a broad class of drugs including prescription painkillers and illicit drugs such as fentanyl and heroin, are involved in about three-quarters of overdose deaths in the U.S., and the number of overdose deaths involving fentanyl has increased sharply since 2015.

The revised 2022 CDC guidelines provide updated recommendations focused on the inclusion of patient-centered insights that focus on a collaboration between multistakeholder groups. The updated guidelines are intended to improve communication on drug safety between patients and clinicians. The guidance encourages appropriate risk-benefit and safety assessments of opioid therapy on a case-by-case basis to ensure flexibility amongst broad populations of patients to ensure safe and equitable access to pain care. It is important to note that these guidelines are for clinicians providing pain care, including those prescribing opioids for outpatients aged 18 years and older, and updates the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain — United States.

The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four key areas: 1) determining whether to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. Further research, prevention and education awareness on opioids and the impacts of the social determinants of health will be necessary in the future to ensure the safe use of opioids is well understood.

Anita Gupta, DO, PharmD, MPP

Board-certified anesthesiologist, pain physician
Adjunct assistant professor, John’s Hopkins School of Medicine
Member, Healio Primary Care Peer Perspective Board

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