new CDC document on opiate prescribing

 On November 4, the CDC released their clinical practice guideline for prescribing opioids for pain: https://www.cdc.gov/mmwr/volumes/71/rr/rr7103a1.htm?s_cid=rr7103a1_w , or DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1 .  A warning: this is a long blog, but hugely shorter than the MMWR article. will embed many of my comments in the Details and Recommendation sections in brackets

 

Details:

-- pain is divided into acute pain (<1month), subacute (1 to 3 months), and chronic (>3 months)

-- one in five adults had chronic pain in the US in 2019 and approximately one in 14 experienced “high impact” chronic pain, defined by high-frequency pain (at least "most days" as well as pain limiting life or work activities

-- chronic pain is also associated with increased likelihood of behavioral health conditions, including mental and substance use disorders, and there is an increased risk for suicidal ideation and behaviors

-- chronic pain is likely to be treated less intensively in nonwhite patients

    -- Black and Latinx people are less likely referred to a pain specialist and they receive prescription opioids at a lower dose; these differences remain after adjusting for access-related factors

    -- clinicians overall give Black patients restricted early refills, and were more likely to discontinue opioids if there was evidence of misuse for Black patients versus white patients

    -- women also may be at higher risk for inadequate pain management than men

-- overall, the data available for us are quite limited, with most studies assessing clinical outcomes at <6 week duration of opiate prescriptions; there is very limited evidence for >1yr [which, by the way, does not mean that some patients do not need continued opiate therapy beyond the one year...]

-- opioid use disorders are associated with diversion, nonmedical use, a 4-fold increase in overdose deaths from 1999 to 2010, and increases in a prescription opioid use disorder.

-- the number of drug overdose deaths in the US increased 28.5% last year from last year to >100,000. And opioid-related deaths from 56,064 to 75,673 (see https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm )

Recommendations: (these do not apply to pain related to sickle-cell disease or cancer or to patients receiving palliative or end-of-life care) [though one could argue that functionally disabling pain for any reason may well be equivalent, and nonopioid therapies may well work for those with cancer...]:

Recommendation I: "Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient, and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy (recommendation category: B; evidence type: 3)" 

-- opioids in several studies are the same or less effective than nonopioids for sprains, strains, tendonitis, bursitis, minor surgeries (eg dental extractions), dental pain, kidney stone pain, and headaches including migraine 

-- clinicians should maximize nonopioid pharmacology (topical or oral NSAIDs, acetaminophen, and nonpharmacological (ice, heat, elevation, immobilization, or exercises) 

    -- the writers do prefer prescribing topical NSAIDs (eg diclofenac gel), which seems to have the best benefit/risk ratio [see http://gmodestmedblogs.blogspot.com/2020/08/acute-musculoskeletal-pain-topical.html for study on this]

-- for major surgery/trauma, opioids may be necessary:  they should be prescribed as needed and no more frequently every 4 hours. And only immediate-release opioids

    -- here are a few blogs done on this situation:

    -- http://gmodestmedblogs.blogspot.com/2018/12/post-op-opiates-too-many-pills-too-many.html , an eye-opening study finding that the vast majority of opiates prescribed after surgery are not necessary, including for open colectomy, small bowel resection, or abdominal hysterectomy

    -- http://gmodestmedblogs.blogspot.com/2021/12/fracture-surgery-weak-opiates-after.html , noting that patients having surgery for orthopedic fractures did as well when they were sent home with acetaminophen with codeine as with oxycodone

    -- http://gmodestmedblogs.blogspot.com/2019/01/restrictive-postop-opioids-fewer-given.html , a study at Roswell Park Comprehensive Cancer Center, highlights an ultra-restrictive opiate prescription protocol (UROPP) for surgery, finding that there was no difference in pain on this restrictive protocol for an array of major and minor surgeries

-- we should make sure in advance that the patient understands the expected benefits, common risks, serious risks, and alternatives; and the patient should be involved in the decision of whether to start opioids (including the risk of unintended long-term opioid use/respiratory depression/constipation/etc

-- for pregnant women:  vaginal delivery -- try acetaminophen or NSAIDs. Same for c-section but add short-acting course of low potency opioids only for as long as they are needed

 

Recommendation 2: "Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks (recommendation category: A; evidence type: 2)"

-- a noninvasive nonpharmacologic approach often helps, including physical therapy (for back pain, fibromyalgia, and hip or knee osteoarthritis), weight loss (for knee osteoarthritis), manual therapies for hip osteoarthritis, psychological therapy, spinal manipulation, low level laser therapy massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehab for low back pain, mind-body practices (yoga, tai chi, qigong, or massage and acupuncture for neck pain; cognitive behavioral therapy (for myofascial massage and yoga/tai chi/qigong), spinal manipulation for neck pain). Of course, many people do not have insurance or their insurance does not cover these nonpharmacologic therapies, and “health systems can improve pain management and reduce medication use and associated risks by increasing reimbursement for and access to noninvasive nonpharmacologic therapies with evidence for effectiveness” 

    -- see http://gmodestmedblogs.blogspot.com/2018/03/opioids-not-better-for-chronic.html for study showing that opioids are not better for chronic back/hip/knee pain than non-opiates 

-- knee pain from osteoarthritis that does not respond to nonpharmacologic interventions, topical NSAIDs can be used. And they should be at the lowest effective dose and shortest duration needed; consider NSAIDs or duloxetine for patients with chronic knee or chronic low back pain; can also consider tricyclic, tetracyclic, and SNRI antidepressants; selected anticonvulsants (pregabalin, gabapentin, oxcarbazepine) and capsaicin and lidocaine patches 

    -- there is some controversy about gabapentanoids for low back or radicular pain benefit (see http://gmodestmedblogs.blogspot.com/2018/07/gabapentinoids-still-not-help-low-back.html ), and there was an FDA warning that they are associatged with respiratory depression and should avoided in those on opioids (see http://gmodestmedblogs.blogspot.com/2020/01/fda-warning-gabapentinoids-and.html )

-- do not consider opioid therapy as first-line or routine therapy for subacute or chronic pain, and if initiated it should be with consideration by the clinician and patient of an exit strategy if the opioid use unsuccessful 

-- clinician seeing new patients who are already on opioids: establish treatment goals, including functional goals, for continued opioid therapy (but avoid rapid tapering or abrupt discontinuation) 

-- patients with subacute pain are at increased risk of transition to chronic pain and long-term opiate therapy. So clinicians should pursue other methods and not just renew the meds 

-- interventional approaches: intraarticular steroid injections provide short-term relief, esp for rheumatoid arthritis, osteoarthritis, rotator cuff disease, but should be supplemented by exercise, PT, and other conservative approaches (weight loss etc)

    -- one RCT comparing 2 years of triamcinolone 40mg vs normal saline injections every 3 months) did find more cartilage loss with the steroids, though by a difference of 0.11mm by knee MRI (unclear of clinical significance). See knee arthritis steroids sl dec cartilage JAMA2017 or doi:10.1001/jama.2017.5283

    -- and, my personal experience, having done very large numbers of knee injections, is that patients' quality of life/functioning typically improves dramatically with injections, sometimes when given rarely (only once, or perhaps repeat in 1-2 years) or if every 3 months or so

 

Recommendation 3: "When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids (recommendation category: A; evidence type: 4)"

-- Long-acting opiates should be reserved for patients with severe, continuous pain [the FDA does say some extended release opioids could be considered for patients who received immediate release opioids daily for at least one week]

-- methadone should not be the first choice because of its risk profile, and should only be used by those familiar with prescribing methadone for pain 

-- studies have found that the effects of opioids on short-term pain and function were consistent across duration of action (shorter long-acting) and opiate type (opioid agonist, partial agonist, or mixed with a non-opioid pain reliever) 

-- fentanyl patches should only be prescribed by clinicians who are familiar with the dosing and absorption properties and be prepared to educate their patients about their use 

 

Recommendation 4: "When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients (recommendation category: A; evidence type: 3)"

-- the lowest dose for opioid-naïve is often equivalent to a single dose of approximately 5 to 10 MME or daily dosage of 20 to 30 MME

-- many patients do not experience benefit in pain or function from increasing the dose to greater than 50 MME per day (diminishing returns), but are exposed to progressive increases in risk (including higher risk of opioid misuse, overdose, death, and falls)

-- Opioid dosages for chronic pain of 50 to <100 MME/day in observational studies have been associated with increased risks for opioid overdose by factors of 1.9–4.6 compared with dosages of 1 to <20 MME/day, and dosages of ≥100 MME/day were found to be associated with increased risks for overdose 2.0–8.9 times the risk compared to 1 to <20 MME/day, after adjusting for confounders on the basis of demographics, comorbidities, concomitant medications, and other factors 

    --  [it should be noted, however, that these are largely observational studies about risks, which do make physiological sense; however, i have not seen any studies on benefits: do patients on a specific dose of opiates (eg 60 MME) benefit from an increase to a higher dose (eg 90 MME) in a study where the incremental 30 MME was either their opiate or placebo??]

-- clinician should use additional caution when initiating opioids for patients over 65 years old, and those with renal or hepatic insufficiency 

Here is their updated chart of MME equivalencies for different opiates (different than prior charts I'vs seen): 

 

 

 

 

Recommendation 5 "For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages (recommendation category: B; evidence type: 4)"

-- The decision to taper opioids should be a mutual decision with informed decision-making 

-- Clinicians should be careful to closely monitor patients who are tapering their medications, and make sure that the patient understands that if they return quickly to their prior dose, since there is an increased risk of overdose because of loss of opioid tolerance. Patient should have naloxone at home [and, when possible, train others at home how to use it]

-- the most appropriate taper in patients who have been on opiates for more than a year should be 10% per month or slower 

-- consider reinforcing non-opioid therapies at the time of tapering 

-- if patients have withdrawal symptoms, alpha-2 agonist (e.g. clonidine and lofexidine) are effective in reducing the severity of withdrawal from heroin or methadone in the context of abrupt discontinuation, which sometimes is necessary 

 Recommendation 6 "When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids (recommendation category: A; evidence type: 4)"

-- “clinicians should generally avoid prescribing additional opioids to patients just in case pain continues longer than expected”

-- patient should be reevaluated at least every 2 weeks if they continue to receive opioids for acute pain

-- if a patient on chronic opioids needs increased pain relief because of superimposed severe acute pain (eg surgery) opioid should be continued only for the duration of the pain severe enough to require them, with a rapid return to baseline

Recommendation 7 "Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients (recommendation category: A; evidence type: 4)"

Recommendation 8: "Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone (recommendation category: A; evidence type: 4)" 

-- Clinicians should regularly assess patients for their alcohol and other drug use, and inform the patients of the increased risk of combinations of substances 

-- patients who are depressed should be treated for that 

-- avoid opiates in patients who have moderate or severe sleep-disordered breathing 

-- avoid opiates in patients who have potentially dangerous jobs 

-- studies have suggested that patients with renal or hepatic insufficiency had increased risk of life-threatening respiratory/CNS depression or overdose 

-- also, patients over 65 years old are at increased risk 

Recommendation 9: "When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose (recommendation category: B; evidence type: 4)"

Recommendation 10: "When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances (recommendation category: B; evidence type: 4)"

-- The results of toxicology screens should not be used in a punitive manner but as a means to improve care

-- “clinician should not dismiss patients from care on the basis of a toxicology test result. Dismissal could have adverse consequences for patient safety, potentially including the patient attaining opiates or other drugs from alternative sources and the clinician missing opportunities to facilitate treatment for substance use disorder”

 

Recommendation 11 "Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants (recommendation category: B; evidence type: 3)" 

-- Though patients who are taking buprenorphine or in methadone programs for opioid use disorder should not have these meds withheld if the patients are also on benzodiazepines or other medications that depress the CNS 

-- in specific situations it might be appropriate to order benzodiazepines in those on opiates, and stopping the benzos might be destabilizing 

    -- [observational studies have suggested that the combination of opiates and benzodiazepines are associated with increased mortality, presumably because of respiratory depression. However, it is notable that many of the conditions for which benzodiazepines are prescribed (e.g. panic attacks, anxiety disorders) themselves confer significant mortality risk] so had to disentangle this 

Recommendation 12 "Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death (recommendation category: A; evidence type: 1)"

-- [It has been clear for many decades through oh-so-many studies that opiate detoxification without medications rarely works]

-- for pregnant women, methadone and buprenorphine for opioid use disorder improve maternal outcomes 

 

Commentary:

-- much of my commentary is embedded above, largely in brackets

-- as with all guidelines, these present a broad scope of desired practice, and there are undoubtedly some patients who will need to deviate from them

-- these recommendations update the less consistent  CDC recommendations of 2016: see http://gmodestmedblogs.blogspot.com/2016/03/new-cdc-guidelines-for-opiate_17.html 

-- there are real concerns about giving even short courses of opiates: for example, one study of women (mean age 69) found that those who happen to be seen by high-intensity opiate prescribers versus low intensity ones in the emergency room had a 30% increase in long-term opiate use, controlling for the severity of their problem: see http://gmodestmedblogs.blogspot.com/2017/02/opiate-prescribing-in-elderly-and.html  . This blog also contains references to several blogs that deal with nonpharmacologic therapies including tai chi, placebo, mindfulness, etc

 

-- even some not-so-strong guidelines (such as what the American Dental Association published: https://www.ada.org/resources/practice/health-and-wellness/opioid-education-for-dentists ) led to significant decreases is opioid prescriptions, see:

    -- a study in Medicaid patients comparing 2012-2019 found that opiate prescriptiions for kids 0-20 decreased from 2.7% to 1.6%; and from 28.6% to 12.2% in adults.  For surgical procedures, adult opioid prescriptions decreased from 48% to 28.7%,  https://jada.ada.org/article/S0002-8177(21)00244-0/pdf    

    --  for a comparison o0f the US with the UK, there is a remarkably lower opiate prescription rate in the UK: http://gmodestmedblogs.blogspot.com/2019/01/opioid-prescriptions-by-dentists.html  

so, 

-- opiate prescribing is one of the most difficult clinical decisions for us clinicians, and it seems like the one creating the most angst for us and our patients

-- one particularly difficult situation is those who are already on opiates: how to taper the opiates over time, especially as the patients get older and may have other comorbidities that increase the opiate risks. my own experience is that it is difficult to convince people that there is a threshold of opiate effect overall, and those on really high doses (MMEs) likely have little benefit but increased risk. And many patients are pretty unreceptive to nonpharmacologic or nonopioid therapies as a means to taper the dose (they may well see those alternatives as a sneaky way to decrease their opiate dose; and they worry that their pain will be worse on a lower dose. my comments that there may be some opiate hyperalgesia at the higher dose and that lowering the dose may be beneficial does not seem to help)

    -- and, even with some of my very long-term patients, who started on opiates decades ago (when the Institute of Medicine, under the "guidance" of Purdue pharmaceuticals, endorsed the "pain as a fifth vital sign" and prodded us to treat pain more aggressively), are concerned now that the tide is shifting with us clinicians as well as in the popular culture that opiates are to be avoided. Unfortunately this can result in a degradation of an otherwise beneficial therapeutic relationship.

-- This CDC report correctly (i think) frames the issue as a collaborative one between the patient and the clinician. The good news is that there seem to be fewer opiate initiations: dentists have decreased them by a lot, emergency rooms often have decreased opiate prescribing effectively (see https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788107 ), some surgical suites in hospitals are effectively using ultra-restrictive opiate prescription protocol (UROPP) to decrease opiates and limit the number prescribed post-discharge.  And, the most frequent way that new people become involved with opiates is by their being extra opiate pills at home in the medicine cabinet.  so, overall, the future seems to be brighter....

geoff

 

If you would like to be on the regular email list for upcoming blogs, please contact me at gmodest@uphams.org

 

to get access to all of the blogs (2 options):

1. go to http://gmodestmedblogs.blogspot.com/ to see them in reverse chronological order

2. click on 3 parallel lines top left, if you want to see blogs by category, then click on "labels" and choose a category​

3. or you can just click on the magnifying glass on top right, then  type in a name in the search box and get all the blogs with that name in them

 

or: go to https://www.bucommunitymedicine.org/ , a website from the Community Medicine section at Boston Medical Center.  This site does have a very searchable and accessible list of my blogs (though there have been a few that did not upload over the last year or two). but overall it is much easier to view blogs and displays more at a time.

 

 

please feel free to circulate this to others. also, if you send me their emails, i can add them to the list