Opioids – Support for Providers

CDC Guideline for Prescribing Opioids for Chronic Pain²

Determining when to Initiate or Continue Opioids for Chronic Pain

1. Opioids are not first-line therapy
   Clinicians should consider opioid therapy only if expected benefits for both pain and function outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
2. Establish Goals for Pain and Function
   Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is not clinically meaningful improvement in pain and function that outweighs risks to patient safety. Morphine milligram equivalents (MME)/day: The amount of morphine an opioid dose is equal to when prescribed, used as a gauge of the abuse and overdose potential of the amount of opioid that is being given at a particular time
3. Discuss Risks and Benefits
   Before starting and regularly 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 Use Immediate-Release Opioids when starting When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
4. Use the Lowest Effective Dose Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to ≥ 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to ≥ 90 MME per day or carefully justify a decision to titrate dosage to ≥ 90 MME per day.
5. Prescribe short durations for acute pain
   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.
6. Evaluate benefits and harms frequently
   Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every three 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.
7. Use strategies to mitigate risk
   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 per day), or concurrent benzodiazepine use, are present.
   Medication-assisted treatment: Treatment for opioid use disorder including medications such as buprenorphine or methadone
8. Review Prescription Drug Monitoring Program (PDMP) data
   
   Clinicians should review the patient’s history of controlled substance prescriptions using state 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 three months.
9. Use urine drug testing
   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.
10. Avoid concurrent opioid and benzodiazepine prescribing, whenever possible.
11. Offer treatment for opioid use disorder
    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.

Reference:
1. HSPJ Coverage Policy – Opioids. https://www.hpsj-mvhp.org/wp-content/uploads/2019/08/Pain-Opioid-2019-05.pdf
2. Centers for Disease Control and Prevention. (2018). Quality improvement and care coordination: implementing the CDC guideline for prescribing opioids for chronic pain. Retrieved from https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf