Treating Chronic Pain and Opioid Prescription the CDC Way
Managing chronic pain has been a key concern for primary care clinicians for a long time. Since opioid use can be detrimental as it may enhance the risks of addiction and overdose, primary care clinicians are always in a dilemma as to how to prescribe opioid painkillers to the patients. Besides, the lack of evidence of long-term efficacy of opioids when administered for chronic pain is making the situation dicier.
To address the problem, the Centers for Disease Control and Prevention (CDC) recently came up with a 12-point guideline to help primary clinicians in treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
The CDC made use of the grading of recommendations assessment, development, and evaluation (GRADE) framework. They conducted a supplemental review on benefits and harms, values and preferences, and costs of opioid administering apart from updating a 2014 systemic review while devising these recommendations.
These recommendations would surely enable the primary care clinicians to take decisions and upgrade their treatment while addressing people with chronic pain. Here, we try to decipher what the CDC has to say about opioid prescription for pain management:
- As suggested by the CDC, clinicians should opt for opioid therapy only when they are sure of the benefits to patients are anticipated to be more than the risk factors.
- There should be a clear view about treatment goals before starting the opioid therapy in terms of pain and function and how the therapy would be discontinued in the advent of adverse outcome, (i.e. when benefits are lesser than risk factors). The opioid therapy should be continued only when benefits outnumber risks in patients.
- It is important for clinicians to discuss in detail about opioid therapy with patients before the start and during the treatment. There should be transparency between them about realistic goals and their respective responsibilities towards the therapy.
- The clinicians are advised to start the opioid therapy with immediate-release opioids for chronic pain management. They should refrain from starting with the extended-release/long-acting (ER/LA) opioids.
- The clinicians should start the opioid treatment with the minimum effective dosage after careful evidence of individual benefits and risks to patients. Even while increasing the dosage, one should exercise extreme caution to avoid pitfalls later on.
- Long-term opioid use usually starts with the treatment of acute pain. But clinicians should always prescribe the lowest dosage of immediate-release opioids. In most instances, it will be for just three days or less.
- The pros and cons of the opioid therapy should be weighed within one to four weeks after the treatment starts. The benefits and risks should be evaluated every three months and if there are more risks than benefits then other complementary treatment should be started and the dosages of opioids should be lessened or completely stopped.
- The clinicians should consider offering naloxone during the process to mitigate risks when there are perceived risk factors like history of overdose, history of substance use disorder, higher opioid dosages or concurrent benzodiazepine use.
- Before starting with the opioid therapy, the clinicians should thoroughly evaluate a patient’s history using the state prescription drug monitoring program (PDMP) data to see whether he or she is at risks of overdose.
- The urine drug testing is a must before the start of the opioid therapy and it should also be conducted annually to assess the presence of any illicit drugs.
- It is advisable for clinicians not to prescribe to opioid pain medication and benzodiazepines concurrently at best.
- The best option for clinicians is to offer an evidence-based treatment, which is a combination of behavioral therapies and medication-assisted treatment with buprenorphine or methadone.
By following these recommendations, the clinicians should be able to avoid and mitigate a lot of risks involved in an opioid prescription to patients with chronic pain.
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