The Centers for Disease Control and Prevention (CDC) released updated guidelines for prescribing opioids for chronic pain (outside of active cancer and palliative and end-of-life care) with the goal of curbing opioid addiction risk.
"It has become increasingly clear that opioids carry substantial risk but only certain benefits – especially compared with other treatments for chronic pain," said Thomas R. Frieden, MD, MPH, director of the CDC. He further noted that the guidelines are meant as "a tool for doctors and patients to chart a safer course."
The CDC made its recommendations based on a literature review of observational studies, as well as consultation with experts and comments from partner organizations and the public. Results from the review were published in the Journal of the American Medical Association. Overall, the researchers determined that opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. They noted, however, that that the studies in the literature review had notable limitations and none evaluated the long-term benefit of opioids for chronic pain.
The guidelines include 12 recommendations, following the key principles of using the lowest-possible effective dosage of opioids and a preference for non-opioid therapies as first-line chronic pain management. Key recommendations include:
- Health-care providers should prescribe over-the-counter pain relievers (ibuprofen or aspirin) prior to prescribing more highly addictive opioids.
- Health-care providers should reduce patient supply of opioids (3-7 days for short-term pain).
- Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain.
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients regarding benefits and risks of opioid treatment.
- Clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
- Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program 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 avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
The guidelines also offer specific information on medication selection, dosage, duration, and when and how to reassess progress and discontinue medication if needed.
The use of opioids for chronic pain has been a topic of debate recently, with some arguing that increased prescribing and sales of opioids have created an epidemic of overuse and abuse, while physicians and others in the pharmaceutical industry fear that restrictions on opioids will create unfair hurdles for patients who need the medication.
While these guidelines do not apply to prescriptions for patients receiving cancer or palliative or end-of-life treatment or those who have had recent surgery, some are concerned that they would impact cancer survivors who have continuing pain. The American Medical Association, for one, has expressed concern that the science backing these recommendations is questionable and that the guidelines could conflict with some state laws.
Sources: CDC press release, March 15, 2016; Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic painâ€”United States, 2016. JAMA. 2016 March 15. [Epub ahead of print.]