Opioid prescribing, CDC

ASSESSING BENEFITS AND HARMS OF OPIOID THERAPY

THE EPIDEMIC

The United States is in the midst of an epidemic of prescription opioid overdose deaths, which killed more than 14,000 people in 2014 alone.

Since 1999, sales of prescription opioids—and related overdose deaths—have quadrupled.

Since 1999, there have been more than

165,000 deaths from overdose related to prescription opioids.

GUIDANCE FOR OPIOID PRESCRIBING

The CDC Guideline for Prescribing Opioids for Chronic Pain1 provides up-to-date guidance on prescribing and weighing the risks and benefits of opioids.

• Before starting and periodically during opioid therapy, discuss the known risks and realistic benefits of opioids.

• Also discuss provider and patient responsibilities for managing therapy.

• Within 1-4 weeks of starting opioid therapy, and at least every 3 months, evaluate benefits and harms with the patient.

ASSESS BENEFITS OF OPIOID THERAPY

Assess your patient’s pain and function regularly. A 30% improvement in pain and function is considered clinically meaningful. Discuss patient-centered goals and improvements in function (such as returning to work and recreational activities) and assess pain using validated instruments such as the 3-item (PEG) Assessment Scale:

1. What number best describes your pain on average in the past week? (from 0=no pain to 10=pain as bad as you can imagine)

2. What number best describes how, during the past week, pain has interfered with your enjoyment of life? (from 0=does not interfere to 10=completely interferes)

3. What number best describes how, during the past week, pain has interfered with your general activity? (from 0=does not interfere to 10=completely interferes)

If your patient does not have a 30% improvement in pain and function, consider reducing dose or tapering and discontinuing opioids. Continue opioids only as a careful decision by you and your patient when improvements in both pain and function outweigh the harms.

1Recommendations do not apply to pain management in the context of active cancer treatment, palliative care, and end-of-life care.

L E A R N M O R E | www.cdc.gov/drugoverdose/prescribing/guideline.html

ASSESS HARMS OF OPIOID THERAPY Long-term opioid therapy can cause harms ranging in severity from constipation and nausea to opioid use disorder and overdose death. Certain factors can increase these risks, and it is important to assess and follow- up regularly to reduce potential harms.

1 ASSESS. Evaluate for factors that could increase your patient’s risk for harm from opioid therapy such as: • Personal or family history of substance use disorder

• Anxiety or depression

• Pregnancy

• Age 65 or older

• COPD or other underlying respiratory conditions

• Renal or hepatic insufficiency

2 CHECK. Consider urine drug testing for other prescription or illicit drugs and check your state’s prescription drug monitoring program (PDMP) for:

• Possible drug interactions (such as benzodiazepines)

• High opioid dosage (≥50 MME/day)

• Obtaining opioids from multiple providers

3 DISCUSS. Ask your patient about concerns and determine any harms they may be experiencing such as:

• Nausea or constipation

• Feeling sedated or confused

• Breathing interruptions during sleep

• Taking or craving more opioids than prescribed or difficulty controlling use

4 OBSERVE. Look for early warning signs for overdose risk such as: • Confusion

• Sedation

• Slurred speech

• Abnormal gait

If harms outweigh any experienced benefits, work with your patient to reduce dose, or taper and discontinue opioids and optimize nonopioid approaches to pain management.

TAPERING AND DISCONTINUING OPIOID THERAPY

Symptoms of opioid withdrawal may include drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tremors. Tapering plans should be individualized. However, in general:

Tapering rates should be individualized and should go slowly enough to minimize symptoms of opioid withdrawal. A decrease of 10% per month is a reasonable starting point if patients have taken opioids for more than a year.

1 Go Slow

2 Consult

Work with appropriate specialists as needed—especially for those at risk of harm from withdrawal such as pregnant patients and those with opioid use disorder.

3 Support

During the taper, ensure patients receive psychosocial support for anxiety. If needed, work with mental health providers and offer or arrange for treatment of opioid use disorder.

Improving the way opioids are prescribed can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs.

L E A R N M O R E | www.cdc.gov/drugoverdose/prescribing/guideline.html