An Overview of Guidelines and Resources Available
Drug overdoses are the No. 1 cause of accidental deaths in the U.S., surpassing deaths by motor vehicle accidents. Many drug overdose deaths involve prescription medications, predominantly opioids. Even greater by orders of magnitude are those patients and their families affected by opioid dependence and addiction.
Guidance strategies to combat the opioid epidemic are now being endorsed by many large public agencies. In this article, we review guidance from the Centers for Disease Control and Prevention (CDC) and the Federal Drug Administration (FDA). These share common themes in their recommendations.
Published in March 2016, the “CDC Guideline for Prescribing Opioids for Chronic Pain” report is directed at primary care physicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. However, the report has recommendations relevant to all prescribers of opioids with extensive analysis of the evidence related to:
- When to initiate or continue opioids for chronic pain
- Opioids selection, dosage, duration follow-up and discontinuation
- Assessing risk and addressing harms of opioids use
MagMutual suggests that all opioid prescribers review the entirety of the report, but we emphasize the following 12 recommendations (note that items 4, 6, and 11 apply to all prescribers of opioids, even short-term):
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain, and clinicians should consider opioid therapy only if benefits for pain and function outweigh risks.
- Before starting opioid therapy for chronic pain, clinicians should establish treatment goals, including realistic goals for pain and function, and consider how opioids therapy will be discontinued.
- Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy, and patient and clinician responsibilities for managing therapy.
- When starting opioid therapy, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
- Clinicians should prescribe the lowest effective dosage, and should carefully reassess evidence of benefits and risks when increasing to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing dosage to ≥90 MME/day.
- Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.
For more patient safety advice and opioid prescribing guidelines click below.