Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs. CDC developed and published the CDC Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.
What is the purpose of the new guideline?
The guideline helps providers make informed decisions about pain treatment for patients 18 and older in primary care settings. The recommendations focus on the use of opioids in treating chronic pain—pain lasting longer than three months or past the time of normal tissue healing. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.
Opioids pose a risk to all patients. The guideline encourages providers to implement best practices for responsible prescribing.
Use nonopioid therapies
Use nonpharmacologic therapies (such as exercise and cognitive behavioral therapy) and nonopioid pharmacologic therapies (such as anti-inflammatories) for chronic pain. Don’t use opioids routinely for chronic pain. When opioids are used, combine them with nonpharmacologic or nonopioid pharmacologic therapy, as appropriate, to provide greater benefits.
Start low and go slow
When opioids are used, prescribe the lowest possible effective dosage and start with immediate-release opioids instead of extended-release/long-acting opioids. Only provide the quantity needed for the expected duration of pain.
Regularly monitor patients to make sure opioids are improving pain and function without causing harm. If benefits do not outweigh harms, optimize other therapies and work with patients to taper or discontinue opioids, if needed.
Centers for Disease Control and Prevention
Talking to Your Patients About Prescription Drug Abuse
Advice for health care providers on screening questions to ask teen and adult patients about possible misuse of prescription drugs. This brochure gives facts about teen prescription drug abuse and its dangers, how teens illegally obtain drugs, and resources for additional help. To access this brochure, click here Talking to Your Patients About Prescription Drug Abuse|SAMHSA
Guideline Information for Patients
Safer, More Effective Pain Management
Living with chronic pain can be challenging. It is essential that you and your doctor discuss treatment options with all of the risks and benefits carefully considered. Some medications, such as prescription opioids, can help relieve pain in the short term but also come with serious risks and potential complications—and must be prescribed and used carefully. Read more……
ASSESS BENEFITS OF OPIOID THERAPY
Assess your patient’s pain and function regularly. A 30% improvement in pain and function is considered clinically meaningful. Discuss patient-centered goals and improvements in function (such as returning to work and recreational activities) and assess pain using validated instruments such as the 3-item (PEG) Assessment Scale:
Screenings for Substance Abuse
The National Institute of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) recommend that physicians screen all patients over the age of 12 for potential substance abuse problems. Patients should be screened at every visit since substance use may change over time. Read More…
How To Do Substance Abuse Screening
Conduct a simple initial screening by asking about tobacco, alcohol, and drug use during the patient interview. Use a routine and non-judgmental approach when asking these questions.
Start with open-ended questions, “Tell me about your alcohol use?” instead of “Do you
drink alcohol?” — assuming that all patients consume some alcohol may yield more
forthright answers. Prove responses by asking about frequency (how many days per
week on average) and quantity (how many drinks on a typical day).
Alternatively, incorporate a short substance abuse screening instrument, like the 4-item
CAGE or CAGE-AID (adapted version that also includes drug abuse), into a health
status questionnaire that all patients complete before their appointment. When
substance abuse is indicated, follow-up with additional interview questions to learn
Patients may be less honest about drug use, but many signs and symptoms of drug use
can be identified through the physical exam, laboratory, or toxicological testing.
Evidence based screening tools for adults and adolescents can be accessed here, Assessment and Screening Instruments
Source: Substance Abuse and Mental Health Services Administration (SAMHSA)
National Institute of Drug Abuse. Click here for PDF.
TAPERING AND DISCONTINUING OPIOID THERAPY
Symptoms of opioid withdrawal may include drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tremors. Tapering plans should be individualized.
In general, the protocol is:
To minimize symptoms of opioid withdrawal, decrease 10% of the original dose per week. Some patients who have taken opioids for a long time might find slower tapers easier (e.g., 10% of the original dosage per month).
Work with appropriate specialists as needed—especially for those at risk of harm from withdrawal such as pregnant patients and those with opioid use disorder.
During the taper, ensure patients receive psychosocial support for anxiety. If needed, work with mental health providers and offer or arrange for treatment of opioid use disorder.
Improving the way opioids are prescribed can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs.
ASSESS HARMS OF OPIOID THERAPY
Long-term opioid therapy can cause harms ranging in severity from constipation and nausea to opioid use disorder and overdose death. Certain factors can increase these risks, and it is important to assess and follow-up regularly to reduce potential harms.
ASSESS. Evaluate for factors that could increase your patient’s risk for harm from opioid therapy such as:
• Personal or family history of substance use disorder
• Anxiety or depression
• Age 65 or older
• COPD or other underlying respiratory conditions
• Renal or hepatic insufficiency
CHECK. Consider urine drug testing for other prescription or illicit drugs and check your state’s prescription drug monitoring program (PDMP) for:
• Possible drug interactions (such as benzodiazepines)
• High opioid dosage (≥50 MME/day)
• Obtaining opioids from multiple providers
DISCUSS. Ask your patient about concerns and determine any harm they may be experiencing such as: