Guidelines for Prescribing Opioids for the Treatment of Chronic Pain

According to America’s Health Rankings Annual Report 2017, drug overdoses are the leading cause of injury deaths in the US. Further, more than 60% of the drug deaths involved an opioid, primarily prescription analgesics or heroin.¹ In 2016, healthcare providers wrote 66.5 opioid prescriptions for every 100 Americans. The same year, 19.1 per 100 persons received one or more opioid prescriptions, with the average patient receiving 3.5 prescriptions.² In 2016, the US Centers for Disease Control and Prevention (CDC) published the “CDC Guideline for Prescribing Opioids for Chronic Pain”.³ The guidelines are intended for patients 18 years and older in primary care settings and are not for use in the active treatment of cancer or patients undergoing palliative or end of life care. This article provides a summary of the 12 recommendations. The intent of the guidelines is to:

• Improve communication between clinicians and patients about the risks and benefits of opioids
• Improve the efficacy and safety of treating pain with opioids
• Reduce the risks of long term opioid therapy

Determining when to initiate or continue opioids for chronic painGuideline

1. Therapies such as non-pharmacologic and non-opioid medications are the preferred treatments for chronic pain. These include exercise therapy, cognitive behavioral therapy, and medications such as acetaminophen, nonsteroidal anti-inflammatory drugs, and selected anticonvulsants . If opioids are used, the expected benefits should outweigh the risks. Opioids should not be used alone but in combination with other therapies.
2. Treatment goals should be established before initiating opioid therapy. The goals must be a realistic determination of pain and function and how these medications may be discontinued if the benefits do not outweigh the risks. To continue opioid therapy, there should be clinically meaningful improvement in pain and function that outweighs risks to patient safety.
3. Before starting opioid therapy, and periodically throughout treatment, clinicians should discuss the risks and benefits with their patients. This should include  expected benefits of opioids, improvement in function as a primary goal, common side effects of opioids, serious adverse effects, risks of opioid use disorder, risks to household members and others if medications are shared, and the importance of periodic reassessment. Clinicians should discuss physician and patient responsibilities in managing the therapy.

Opioid Selection and Duration

4. When starting opioid therapy, clinicians should prescribe immediate release opioids, which have a shorter duration of action, rather than extended-release formulations. ER-Long acting formulations should be used for severe, continuous pain and should only be considered for patients who have received immediate release opioids daily for at least one week. In general, it is preferable that clinicians avoid the concomitant use of immediate release and ER-LA opioids.
5. When starting, patients should be prescribed the lowest effective dose. A careful reassessment of individual risks and benefits should be made when a clinician is considering increasing the dosage to ≥ 50 morphine milligram equivalents per day . Physicians should avoid increasing the dosage to ≥ 90 MME/day. Careful justification is necessary to decide to titrate the dosage ≥ 90 MME/day.
6. Chronic use of opioids often begins with the use of opioids to treat acute pain. Therefore, in treating acute pain, clinicians should prescribe the lowest effective dose of immediate release opioids and for no longer than the expected duration of pain severe enough to require opioids. This is typically 3 days or less and rarely more than 7 days. Within 1-4 weeks of starting opioid therapy or after increasing the dose, clinicians should evaluate the benefits and harms with their patients. This should include benefits in function, pain control, and quality of life. These evaluations should also be performed at least every 3 months of continued therapy. If harms outweigh the benefits of continued opioid use, clinicians should optimize other therapies and engage patients in decreasing dosage or decreasing with a goal of discontinuing opioid therapy. When opioids are reduced or discontinued, a taper slow enough to minimize signs and symptoms of opioid withdrawal should be used.

Assessing Risk and Addressing Harm

7. Clinicians should evaluate risk factors for opioid-related harm before initiating and periodically during opioid therapy. The management plan should include strategies to mitigate risk such as offering naloxone when there is an increased risk for opioid overdose, such as high dosages (≥ 50 MME/day) and history of substance use disorder.
8. Clinicians should use the state Prescription Drug Monitoring Program (PDMP) to review a patient’s history of controlled substance prescriptions. PDMP data should be reviewed at the beginning of therapy and then with every prescription to no less frequently than every 3 months.
9. Urine drug testing (UDT) should be utilized by clinicians before starting opioid therapy. With continued therapy, UDT should be considered at least annually. Healthcare practitioners should explain to patients that the purpose of the testing is to improve safety. UDT should include the prescribed opioids, and other controlled substances and illicit drugs which increase the risk of overdose when used in conjunction with opioids.  These include opioids which were not prescribed, heroin and benzodiazepines. UDT may be performed by immunoassay (IA), using a panel for commonly prescribed opioids and illicit drugs. Clinicians should be familiar with drugs included in urine drug testing IA panels and which drugs may require more specific testing to be detected. Clinicians should not test for drugs for which the presence or absence will not affect management of the patient. Prior to ordering UDT, physicians should have a plan for addressing unexpected results. If unexpected IA results are not explained, specific definitive testing, typically by mass spectrometry, may be necessary.
10. Clinicians should avoid prescribing benzodiazepines concurrently when a patient is receiving opioid pain medication whenever possible. In addition, clinicians should consider the benefits and risks of prescribing other central nervous system (CNS) depressant drugs, such as muscle relaxants, in combination with opioids. Physicians should consider including other healthcare providers such as pain specialists, and mental health professionals in the care of a patient co-prescribed opioids and other CNS depressants.
11. For patients with opioid use disorder, clinicians should offer or arrange for evidence based treatment. Treatment is usually medication assisted with buprenorphine or methadone along with behavioral therapies.

In summary, opioids should not be first line treatment for chronic pain. When making decisions regarding use of opioids, healthcare providers should establish goals for pain and function with their patients and engage in open discussion of risks and benefits. Immediate release formulations and the lowest effective dose should be used when initiating therapy. There should be frequent assessment of treatment benefits and harms with the adoption of strategies to mitigate risk.  Urine drug testing using immunoassay panels permits rapid screening for multiple drugs. Definitive or confirmation testing, with mass spectrometry, should be used for drugs for which there is no immunoassay available, such as gabapentin; if the screen results are inconsistent with clinical expectations; and if quantitative results are required. When appropriate, clinicians should engage the laboratory or toxicologist in discussion regarding suitable test ordering and interpretation of test results.For additional information, refer to the references below.Amanda J. Jenkins, Ph.D, is Scientific Director, Toxicology, Quest Diagnostics, based in Marlborough, Mass., and Associate Professor, Pathology, UMass Medical School in Worcester, Mass.

References:1. America’s Health Rankings, United Health Foundation. A call to action for individuals and their communities. Annual Report 2017. www.AmericasHealthRankings.org/AR17/Drugdeaths. Accessed December 27, 20182. Mattson CL, Schieber L, Scholl L, et al. Annual Surveillance Report of Drug-Related Risks and Outcomes United States, 2017. United States Department of Health and Human Services. https://www.cdc.gov/drugoverdose/pdf/pubs/2017-cdc-drug-surveillance-report.pdf. Accessed December 27, 2017.3. CDC Guideline for Prescribing Opioids for Chronic Pain-United States, 2016. www.cdc.gov/drugoverdose/prescribing/guideline.html. Accessed December 27, 2017.