{"id":933,"date":"2015-12-23T21:00:56","date_gmt":"2015-12-23T21:00:56","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=933"},"modified":"2017-08-21T11:12:47","modified_gmt":"2017-08-21T11:12:47","slug":"primary-care-corner-with-geoffrey-modest-md-new-cdc-recommendations-for-opiate-prescribing","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/12\/23\/primary-care-corner-with-geoffrey-modest-md-new-cdc-recommendations-for-opiate-prescribing\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: New CDC Recommendations for Opiate Prescribing"},"content":{"rendered":"

By Dr. Geoffrey Modest <\/strong><\/p>\n

The CDC just came out with draft guidelines for prescribing opiates for chronic pain (see\u00a0http:\/\/www.regulations.gov\/#!documentDetail;D=CDC-2015-0112-0002<\/a>\u200b ). These draft recommendations include the following regarding when to initiate or continue prescribing opiates.<\/p>\n

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  1. Nonpharmacologic therapy and nonopioid meds are preferred for chronic pain. There are no data supporting chronic opiates, so hard to recommend given their known risks, except for this little caveat: “no study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for chronic pain evaluated long-term (>1 year) outcomes related to pain, function, or quality of life. Most placebo-controlled randomized trials were <= 6 weeks in duration”. So, no data really. There is a comment that it’s okay for end-of-life care (commenting that “evidence of long-term opioid therapy for chronic pain outside of end-of-life care remains limited”), which does suggest there may be benefit (and, I\u2019m not sure what the real difference in subjective pain is, comparing those at end-of life and those not). \u00a0My point is that there are basically no data, that in my experience there are patients with really bad chronic pain who pretty clearly benefit from opiates and sometimes higher doses, ands this puts us providers in a bind. There is no question to me that trying nonpharmacologic therapy is really important (PT, weight loss in those with knee pain etc., massage\/manipulation, psych therapy and esp CBT, exercise…., and combinations of these). And that non-opioid therapies often help (acetaminophen, etc… though I am concerned that prolonged NSAID use has its very real problems for the GI tract and heart especially, and significant mortality), but I should add that some of these drugs (e.g. salsalate) are off the Medicare-approved list for unknown reasons, are benign, but\u00a0sometimes work well. And local steroid injections often give reasonably long-term relief (e.g. joint injections, trigger point injections) in my experience, as well as other pain meds such as\u00a0tricyclics, anticonvulsants (pregabalin, gabapentin, carbamazepine), and SNRIs. I would further reinforce avoiding opiates unless really needed,\u00a0the above often work, and it is clear that opioids do have significant harms (abuse\/overdoses, MIs, car accidents…)<\/li>\n
  2. Before starting opioids for chronic pain, prescribers should establish realistic treatment goals with patients in\u00a0terms of pain and function. This applies to pain lasting >3 months or past the time of normal tissue healing<\/li>\n
  3. There should be periodic discussions with patients taking opioids about the risks and realistic benefits of continued use, as well as the patient and provider responsibilities for managing therapy. This includes safety issues, which might be uncovered by looking at the prescription drug monitoring program (PDMP). Again, the issue is: unknown benefit (i.e., not studied, though the patient may attest to the benefit) but clear risks<\/li>\n
  4. When starting opioids, use immediate-release ones, not the extended-release ones. (The latter have likely increased potential for overdose, and, as I have mentioned in earlier blogs, there really are no data showing that long-acting ones are better, either more effective or safer). If you decide to switch from short to long-acting and are switching opioids, remember that there is incomplete cross-tolerance, so the dose of the long-acting med should be reduced. Also, given the above, they recommend NOT giving long-acting along with short-acting opiates (this is pretty different from the old model: give long-acting to get steady state of opiates, then short-acting for “breakthrough” pain). Also given the [not-so-scientific] data finding more deaths with methadone, that should\u00a0not be the\u00a0first agent to use for a long-acting one.<\/li>\n
  5. Use the lowest effective\u00a0dose of opiates. And especially if increasing the dose to >50 morphine milligram equivalents (MME)\/day. And “generally avoid increasing the dosage to >=90 MME\/day”. One interesting contradiction is that methadone maintenance programs often have people above 100mg methadone\/day (that is, >300 MME) for the longterm. In fact I have a chronic pain patient who is in a methadone program and on 70mg for the past many years. Given the presumed benefit of TID dosing of methadone for chronic pain, I appealed to the Medicaid program in Massachusetts so I could\u00a0give him 70mg of methadone in divided doses at the health center but was unable to get approval for more than 60mg, the Medicaid max. However, I was told I could give him 60mg of methadone and an almost\u00a0unlimited amount of oxycodone along with it….. The above dosage restriction, as pointed out in prior blogs, comes from ecological data showing that those on higher doses (e.g. >100 MME\/day) have higher risk of overdoses and\u00a0deaths. But, again, there are NO (as in zero) randomized controlled\u00a0studies looking at the benefits of higher vs lower doses. And I certainly have some chronic pain patients who are on high doses for a long time and who are very willing to take risks in order to get “better pain relief and function”, from their perspective (part of the issue may be genetic variants in mu receptors \u2013 see past blogs as listed at the end). Also, we should consider giving naloxone kits to patients on opioids in case there is an overdose, esp if they are on higher doses of opiates.<\/li>\n
  6. Chronic opiate use begins with acute pain therapy. So, for acute pain, we should also give the lowest dose possible and shortest duration of immediate-release opiates (and ERs should not blithely prescribe opiates). And “3 or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery”. The 3-days is largely\u00a0“expert opinion”, though there was a study in patients with acute low back pain showing that there was usually a significant decrease in pain by the 4th day. And another one I blogged on recently (see blogs below) not finding that opiates were in fact better than nonopiates for acute low back pain.<\/li>\n
  7. Evaluate benefits and harms within 1-4 weeks of starting opiates and at least every 3 months thereafter. There may be utility to using validated scales to assess function, pain control and quality of life (e.g. PEG scale–Pain average, interference with Enjoyment of life, and interference with General activity). The recommended rate of tapering doses is not clear, some suggesting rapid tapers over 2-3 weeks in those with severe adverse events (e.g. overdose), others recommend slower tapers at 10%\/week.<\/li>\n
  8. Before starting and periodically thereafter, evaluate risk factors for opiate-related harms.<\/li>\n<\/ol>\n