Overview of CDC Guidelines regarding Pain Management

The Center for Disease Control and Prevention (CDC) released guideline recommendations for primary care doctors who are prescribing chronic pain medications. These guidelines, release in March 2015, are for those patients who do not have active caner of end-of-life care.

The CDC developed these guidelines using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and they are based on scientific evidence regarding benefits and harms, resource allocation, and values and preferences.

While patients need proper pain management, the guidelines are intended to improve the communication between the patients and doctors regarding opioid therapy for chronic pain, and they were developed to improve the effectiveness and safety of pain treatment, while reducing the risks associated with long-term narcotic therapy.

Determining when to Initiate of Continue Opioids for Chronic Pain

1. Nonpharmacologic therapy and nonopioid medications are preferred for chronic pain. The doctor should consider opioid therapy only if the benefits for both function and pain outweigh the risks for the patient. Therapies include physical therapy, cognitive behavioral therapy, weight loss, joint injections, and epidural steroid injections.
2. Before starting opioid therapy for chronic pain, doctors should establish standard treatment goals with the patient, and should consider how opioid therapy will be discontinued if the benefits do not outweigh risks.
3. Before starting opioid therapy, and periodically during the therapy, clinicians should discuss known risks and benefits with the patient. The doctor should emphasize that improvement in function is the main goal, and this can occur even when pain is still present.

Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation

4. When starting opioid therapy for chronic pain, doctors should prescribe immediate-release agents instead of long-acting or extended release opioids.
5. When opioids are started, clinicians should start with the lowest effective dose. In addition, the doctor should use caution, should carefully reassess evidence of patient benefits vs. risks, and should avoid increasing the dose.
6. Long-term opioid use begins with treatment for acute pain. When opioids are used for pain, doctors should prescribe the lowest effective dose, and avoid long-acting medications. In addition, clinicians should prescribe no greater quantity than needed for the expected duration of pain.
7. Clinicians must evaluate the benefits and risks with patients within 1-4 weeks of staring opioid therapy for chronic pain, or before increasing the dose. The doctors should evaluate the patient every 3 months or more frequently regarding risks and benefits.

Assessing Risks and Addressing Harms of Opioid Use

8. Before starting, and periodically during continuation of opioid therapy, clinicians should evaluate for risk factors and harms. In addition, clinicians should incorporate management plan strategies to mitigate risks, such as offering naloxone.
9. Clinicians should review the patient’s history using the state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving dangerous combinations or opioids from another source. Clinicians should review this periodically during opioid therapy.
10. When prescribing opioids for chronic pain, doctors should use urine drug testing before starting opioid therapy, and consider urine drug testing every year to assess for prescribed medications and other drugs.
11. Clinicians should avoid prescribing opioid pain medicines and benzodiazepines together when possible.
12. Clinicians should arrange evidence-based treatment, or offer it, for people with opioid use disorder. This involves medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies.

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Resources

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR, 65(1), 1-49.