The Centers for Disease Control and Prevention recently released a dozen best practices for primary care providers to follow in prescribing opioid pain relievers to adult patients. The guidelines are geared toward those with chronic pain, defined as lasting more than three months, or past the typical time of healing, in patients outside of cancer and end-of-life care. The strategies — which emerged from a rigorous process of weighing quality evidence and costs, among other things — are still in draft form, and the agency hopes to finalize them in the coming months. They are as follows:
1. Therapies that don’t use opioids or other pharmaceuticals for chronic pain are preferred. Only consider using opioid therapy if the expected benefits for pain relief will likely outweigh the risks to the patient.
2. Before starting a patient on opioids for chronic pain, set treatment goals with patients related to pain relief and function. Don’t start opioid therapy without first deciding how it will be discontinued if the meds fail, and only continue therapy if clinically meaningful improvement to pain and function is made that outweighs risks to patient safety.
3. Prior to opioid therapy, doctors must discuss known risks, realistic benefits and both parties’ responsibilities to manage care.
4. When starting a patient on opioids, prescribe those of the immediate-release variety, rather than extended or long-acting release.
5. Start by prescribing the lowest effective dosage possible, use caution and implement precautions when upping dosage.
6. Prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days are typically sufficient for most non-traumatic pain not tied to major surgery.
7. Weigh the benefits and harms with patients within one to four weeks of starting a patient on opioids. Also, evaluate benefits and harms with patients at least every three months, and if those are outweighed by potential harm, work to reduce dosage toward eventual discontinuation.
8. Incorporate into the treatment plan strategies to mitigate risk to the patient, including considering offering naxolone — a medication used to reverse the effects of opioids — when a patient displays factors that increase risk for opioid overdose.
9. Review the patient’s history of substance use by tapping into the state prescription drug monitoring program to determine whether he or she is receiving high opioid dosages or dangerous combinations that create a higher risk for overdose.
10. Drug test patients before initiating opioid use, and continue such testing at least annually to watch out for other prescribed medications, along with other illicit drugs that show up in screenings.
11. Where possible, avoid prescribing opioid pain meds for those who are receiving benzodiazepines — a class of psychoactive drugs which increase toxicity and the potential for overdose when mixed.
12. Offer or arrange evidence-based treatments — such as medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies—for patients with an opioid disorder.