March 15, 2016, the Centers for Disease Control (“CDC”) issued an extensive
report and accompanying checklist resources entitled “CDC Guidelines for
Prescribing Opioids for Chronic Pain – United States, 2016” (“Guidelines”)
While the title describes a focus on opioids and chronic pain, the Guidelines
include important analyses and recommendations relating to acute pain treatment
and non-opioid treatment options.
Ultimately, the Guidelines describe a high
degree of attentiveness to the risks and benefits of opioid treatment and
pharmacological, as well as non-pharmacological, options to opioid
treatment. This attention presumes
careful, individualized assessments, discussions, monitoring, reassessments and
adjustments in treating pain issues.
This is a valuable resource. At
the same time, it serves as an important contribution to “best practices
standards” that will heighten both expectations and risk exposure for all
healthcare providers, not just pain management specialists.
It is important to note that the
Guidelines are directed at primary care physicians who are prescribing opioids
for chronic pain outside of active cancer treatment, palliative care,
and end-of-life care. These latter
exclusions are noticeable because some providers in those specialty settings
have been concerned that increased scrutiny can lead to undue caution about use
of opioids in those situations where addiction is a secondary issue. The stated purpose of the Guidelines is to
“improve communication between clinicians 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 opioid use disorder, overdose and death.”
The Guidelines contain twelve
recommendations broken down into three areas for consideration that can be
summarized as (i) use non-opioid therapies; (ii) start low and go slow; and
(iii) follow up:
A. Determining when to initiate or
continue opioids for chronic pain (defined as equal to or greater than three
1. The Guidelines start from the
perspective that non-pharmacological therapy and non-opioid pharmacologic
therapy is preferred for chronic pain.
Clinicians are encouraged to balance the benefits versus the risks when
considering opioid therapy, and attempt to combine it with non-opioid
2. Before starting opioid therapy for
chronic pain, clinicians should establish treatment goals that are realistic
and openly anticipate discontinuation of opioids if benefits do not outweigh
3. Before starting opioid therapy, and
periodically during the therapy, clinicians should discuss with patients known
risks and realistic benefits of the opioid therapy.
B. Opioid selection, dosage, duration,
follow-up, and discontinuation.
1. When starting opioid therapy for
chronic pain, immediate-release rather than extended-release opioids should be
2. Clinicians should start with the
lowest effective dosage.
3. Prescriptions should be for the
expected duration of the pain, which will often be three days or less, and
rarely more than seven days.
4. Clinicians should evaluate benefits
and harms with patients within one to four weeks, and then at least every three
C. Assessing risk and addressing harms of
1. Clinicians should incorporate
strategies to mitigate risk into the management plan.
2. Clinicians should use state
prescription drug monitoring programs to review past controlled substance
prescriptions and dangerous combinations for the patients.
3. Clinicians should use urine drug
testing before starting opioid therapy.
4. Clinicians should avoid prescribing
opioid pain medication and benzodiazepines concurrently whenever possible.
5. Clinicians should offer or arrange for
evidence-based treatment, including behavioral therapies, for patients with
opioid use disorder.
Guidelines provide an extended discussion of the background and rationale for
the development of these recommendations.
There is also an attempt to compile and update the current state of
research and clinical information regarding pain treatment and risk assessment
and mitigation. Part of the urgency is
reflected in a variety of statistics, including the fact that the death rate
associated with opioid pain medication has “increased markedly,” while the
death rate for other leading causes of death such as heart disease and cancer
have “decreased substantially.”
is a link to the Guidelines, along with very useful resources, including
checklists, guidelines and treatment alternatives.
Guidelines provide inpatient guidance for all healthcare providers, especially
in light of the publicity surrounding opioid abuse and increased regulatory
scrutiny and enforcement activity.
Additional information about Plews Shadley Racher & Braun
LLP and its health care practice is available at www.psrb.com.
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