CDC Guidelines For Prescribing Opioids-The Waves Of Change Just Began…

As a practicing pain specialist, one of the choices of medications available for me to treat pain is opioids. I have wondered, awaited, and longed for “some authority” to get involved and recommend guidelines for opioid prescribing. Recently, many practitioners who have a DEA number claim to be “a pain specialist”. This has created chaos. I personally have seen some clinical pain disasters and unfortunately still see them. We owe better pain care for our people. We also owe the public an understanding of these guidelines and empower patients to know their rights. I have edited these guidelines to make them simple and understandable. (Please see footnote for main reference). They are as follows:

1-For treating chronic pain, non-opioid therapy is preferred and opioids should not be the first line of treatment. If used, combine them with non-opioids (such as Tylenol, NSAIDS, Gabapentin, Pregabalin, Duloxetine…)

2-Establish realistic treatment goals for pain and function. Think about how you’ll discontinue opiates. Continue only if clinical and meaningful improvement in pain and function is perceived.

3-Before starting, and periodically during treatment, explain the risks and benefits of non-opioid availability for treating your patients

4-When starting opioids, use short acting type rather than long acting.

5-Start low and go slow. Start with lowest dose possible. Always carefully assess the risks and benefits when increasing the dose.

6-For acute pain, don’t prescribe more than needed. Continuously monitor if higher doses are needed. For acute pain, 3 days worth of pain medication is usually sufficient.

7-For acute pain, do not prescribe long acting opioids. Prescribe the lowest effective short acting pain medication. Reduce, or taper, and discontinue if needed.

8-Mitigate risk factors such as avoiding the simultaneous use of opioids and benzodiazepines (such as Valium and Xanax). If there is a history of overdose, consider prescribing naloxone (to reverse narcotic effects)

9-Assess the risk and benefits of opioid use initially and at least every 3 months. Review the controlled substance prescription drug monitoring (it is an online data available for prescribers to see the prescribing profile of patients).

10-Use initial urine drug toxicity testing and in follow ups, if needed.

11-Avoid mixing opioids and benzodiazepines concurrently, when possible

12-If a patient has opioid misuse disorder arrange for him/her for alternative treatment such as methadone or suboxone treatment, in combination with behavioral therapy programs.

Notice the emphasis on pain AND function in this guideline. Although pain patients have the right to be treated, their treatment outcome should determine if their function is getting better or not. Functionality is essential as it makes an individual part of the society again; the true meaning of a good citizen.

My opinion: This is long and overdue. I appreciate this and what it stands for. I feel that finally someone is paying attention to this issue…

Reference: CDC Guideline For Prescribing Opioids For Chronic Pain-United States, 2016. Dowell D et al. Center for Disease Control and Prevention. Recommendations and Reports/March 18, 2016/65(1); 1–49