Abstract
This guideline provides recommendations for primary care providers who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses (1) when to initiate or continue opioids for chronic pain; (2) opioid selection, dosage, duration, follow-up, and discontinuation; and (3) assessing risk and addressing harms of opioid use. This guideline is intended to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including abuse, dependence, overdose, and death.
Source: Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1.
Introduction
On March 18, 2016, the Centers for Disease Control and Prevention (CDC) officially published the Guideline for Prescribing Opioids for Chronic Pain in the Recommendations and Reports series of the CDC’s Morbidity and Mortality Weekly Report. The recommendations are designed to improve patient safety for those with chronic pain and are a strategy to address the ongoing prescription opioid overdose epidemic.
CDC’s guideline is not a panacea for the opioid problem or the pain problem, but it is an important step toward more cautious prescribing of opioids.
The Guideline will be an important tool for providers and patients together to develop plans for safe and effective pain treatment. From 1999 to 2014, more than 165 000 people died from overdose related to prescription opioids. Since 1999, prescribing of opioids has quadrupled, without a change in the amount of pain Americans report. This increase in prescribing is a key driver of the opioid overdose epidemic.
CDC’s National Center for Injury Prevention and Control was one of the first to sound the alarm in the early 2000s about the increasing number of deaths among adults from unintentional poisonings and published an article in 2006 on the dramatic increase in poisoning mortality rates and the sales of opioid analgesics nationwide (Paulozzi LJ, Budnitz SD, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiology Drug Saf. 2006;15(9):618-627).
The authors noted prevention efforts should reduce deaths without diminishing the quality of care for patients. Since the earliest days of the CDC’s work on this issue, there has been an attempt to balance the dual public health issues of prescription opioid overdoses and chronic pain.
The Recommendations
Patients with chronic pain deserve safer and more effective pain management. The guideline provides recommendations about the appropriate prescribing of opioids to improve pain management and patient safety. The guideline is intended for primary care providers who are treating adult patients for chronic pain and is not intended for active cancer treatment, palliative care, and end-of-life care. Key recommendations include the following:
Non–opioid therapy is preferred for chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
When opioids are used, providers should prescribe the lowest effective dosage.
Providers should work with patients to establish pain treatment goals, check for improvements in pain and function regularly, and taper or discontinue opioids if a patient experiences harm.
At the heart of the guideline is an effort to improve communication between providers and patients about the risks and benefits of prescription opioids. We believe that patients deserve the opportunity to learn about new evidence on risks of opioids, particularly at higher dosages, to reevaluate whether continuing their current treatment continues is the best available option, or to consider changing course if they and their provider determine—together—that this makes sense.
The Process
CDC developed the guideline using a rigorous process based on the best available scientific evidence and input from experts, including nationally recognized researchers, providers, and partners. The extensive development process included scientific review, expert review and input, peer review, public comment, and federal advisory committee review. The input by many experts, the public, and stakeholder organizations has resulted in a document that will give primary care providers the tools needed to address safer prescribing of opioids.
This guideline is a balanced approach to achieving the goal of helping physicians manage chronic pain better and safer with their patients, and these recommendations will make a difference in saving lives in the United States.
The Resources
CDC has also developed user-friendly resources to make the guideline easy for providers and patients to understand and use. Materials for download include information for patients and tools to help providers implement the recommendations, such as a decision checklist, fact sheets, and posters. Additional resources available include the following:
CDC website with information and resources for patients, overview of guideline for providers, fact sheets, clinical tools, and other materials related to the guideline.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016 [published online March 15, 2016]. JAMA. doi:10.1001/jama.2016.1464. http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2016.1464
Scott LC, Lewis S. Opioids for chronic pain [published online March 15, 2016]. JAMA. doi:10.1001/jama.2016.3224. http://jama.jamanetwork.com/article.aspx?articleid=2503507
Frieden TR, Houry D. Reducing the risks of relief: the CDC opioid-prescribing guideline [published online March 15, 2016]. N Engl J Med. doi:10.1056/NEJMp1515917. www.nejm.org/doi/full/10.1056/NEJMp1515917