As the concerns surrounding opioid use have evolved, there have been more guidelines and organizations recommending guidance on prescribing practices of opioids. Today, we’ll be breaking down what you need to know from the 2022 CDC Opioid Guidelines’ recent update for prescribing opioids for pain. The guideline contains 12 specific recommendations surrounding when to use opioids, which opioids to use and their dosing, determination of therapy duration and follow-up, and how to assess risks and mitigate the harm of opioids. One very important caveat to remember with these guidelines: they do not apply to sickle cell disease, cancer, or palliative/end-of-life care.
The first section of the guideline focuses on when to use opioids. They focus on recommending possible alternative therapies, including non-pharmacological therapies and other nonopioid pharmacological therapies which are considered at least as effective or more effective compared to opioids. Options such as NSAIDs, acetaminophen, muscle relaxers, and even agents such as gabapentin and duloxetine are recommended prior to opioids in appropriate clinical situations. These alternative therapies should ideally be maximized prior to opioids.
The next section of the 2022 CDC Opioid Guidelines focuses on which opioids to use and appropriate dosing. Immediate-release opioid options should always be used for acute situations. Extended-release opioids are not recommended for those who have not previously been taking around-the-clock opioids often for at least a week and are typically reserved for chronic pain management. It is also recommended that the lowest effective dose be used. Risk versus benefit should be considered prior to dosage increases. Additionally, limited evidence has been found for additional efficacy beyond 50 MME/day, although this is not a hard limit that is recommended.
The guideline also discusses the duration of opioid use and discontinuation. If a patient presents that is already taking opioid therapy, the risk versus benefit should be assessed. If the benefit is higher, therapy can be continued but other therapies should be maximized and opioid therapy should be closely monitored. If the risk is higher, other therapies should still be maximized, however, opioid therapy can be slowly discontinued. It is noted that opioid therapy should never be stopped abruptly after extended use unless life-threatening situations occur. In regards to patients in acute pain, opioids should be prescribed for no longer than the pain is expected to be experienced.
The last section of the guideline looks at monitoring, risk assessment, and risk mitigation. The CDC recommends reevaluation of risks and benefits within 1-4 weeks of starting opioid therapy and periodically thereafter if therapy continues. Risk mitigation strategies, such as offering naloxone, should be used regularly. The update also recommends using PDMP to evaluate a patient’s risk for overdose including any interacting medications such as benzodiazepines, however, they note a patient should not be excluded from care due to these risk scores. Toxicology should be considered if necessary, however, providers should use caution and consider the benefits and risks. Finally, providers should arrange for treatment for patients with opioid use disorder as detoxification without opioid use disorder medications can be much more dangerous. Here is a classic case from a guest contributor of inappropriate prescribing of opioids.
The 12 main recommendations have been paraphrased and summarized below.
- Nonopioid therapies are often at least as effective as opioids for acute pain situations and the use of these therapies should be maximized prior to opioids if appropriate.
- Nonopioid therapies are preferred for subacute and chronic pain and the use of these therapies should be maximized as appropriate prior to opioid consideration.
- When starting opioid therapy, immediate-release options should be chosen.
- The lowest effective dose of opioids should be used.
- Risk and benefit should be continuously assessed and appropriately discontinued if ineffective or unsafe.
- Opioids should be prescribed for the shortest duration of expected need.
- Patients should be reevaluated within 1-4 weeks of starting or increasing opioid therapy.
- Patients should be periodically evaluated for opioid-related harms and should be offered naloxone.
- Prescribers should utilize PDMP as a tool to assess patient risk versus benefit.
- Toxicology screening should be considered on a risk versus benefit basis.
- Prescribers should use caution with concurrent opioid use with benzodiazepines and other CNS depressants.
- Prescribers should offer or arrange for appropriate treatment of opioid use disorder when needed with evidence-based medications.
Comparing the updated 2022 CDC Opioid Guidelines with the previous 2016 guidelines, there were several new items and changed items. Regarding new additions, the 2022 guidelines utilized new data to include recommendations for acute pain and subacute pain. The updated guidelines also include new guiding principles for the implementation of recommendations as well as information regarding health equity and disparities in the treatment of pain.
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This article was written by Jordan Erkel, PharmD Candidate in collaboration with Eric Christianson, PharmD, BCPS, BCGP
References
Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95.
What specific therapies are at least effective as opioids and what is the quality of the evidence, per the guidance for this recommendation? “non-pharmacological therapies and other nonopioid pharmacological therapies which are considered at least as effective or more effective compared to opioids”