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CDC Releases Opiate Guidelines

Darrell Hulisz, RPh, PharmD
Michael Buskey, P

March 2, 2016

The Center for Disease Control and Prevention (CDC) recently released a draft guideline for public comment regarding prescribing opiates. The goals of the guideline are to improve communication between providers and patients about the risks and benefits of opioid therapy for chronic pain, to improve the safety and effectiveness of pain treatment, and to reduce the risks associated with long-term opioid therapy. The guideline addresses the use of opioid pain medication in certain special populations (e.g., older adults and pregnant women) and in populations with conditions posing special risks (e.g., a history of substance use disorder). The CDC stresses that the recommendations are not intended to provide guidance on use of opioids as part of medication-assisted treatment for opioid use disorder.

Highlights of the guideline include a recommendation that for chronic pain, non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred. Before initiating opiates for chronic pain, prescribers should establish treatment goals with all patients, including realistic goals for pain and function. Prescribers should discuss known risks and realistic benefits of opioid therapy with the patient, and treatment. One area that may be controversial is the CDC's recommendation to initiate chronic pain management with immediate-release opioids, rather than extended-release/long-acting opioids. Therapy should be initiated with the lowest effective opiate dose, with additional precaution when increasing morphine to ?50 morphine milligram equivalents (MME)/day, and prescribers should generally avoid increasing the dosage to ?90 MME/day. ?

In the management of acute pain, the lowest effective dose of immediate-release opioids should be prescribed with no greater quantity than needed for the expected duration of pain severe enough to require opioids. The guideline suggests that three or fewer days should be sufficient for most non-traumatic pain not related to major surgery. Within 1-4 weeks of either initiation for chronic pain or escalation of dose, providers should evaluate the benefits and harms with their patients, and evaluate benefits and harms of continued treatment at least every 3 months.

Additional recommendations include providers reviewing the patient's history of controlled substance prescriptions using state prescription drug monitoring programs, both prior to prescribing opiates and at regular intervals. It is also recommended that providers use urine drug testing before starting chronic opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. Pharmacists are able to review the full draft of the document here: http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0002

1. Draft CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0002 Accessed February 25, 2016.

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