Prescribing and sales of opioids in the United States have quadrupled since 1999, which has led to a prescription opioid overdose epidemic.
So as part of a unified and accelerated effort from the government to combat this crisis, on March 15, the CDC issued its final Guideline for Prescribing Opioids for Chronic Pain -- United States, 2016.(www.cdc.gov) The guideline is intended for use by primary care health professionals who are treating patients with chronic pain (i.e., pain lasting longer than three months or past the time of normal tissue healing) in outpatient settings.
"More than 40 Americans die each day from prescription opioid overdoses; we must act now," said CDC Director Tom Frieden, M.D., M.P.H., in a news release.(www.cdc.gov) "Overprescribing opioids -- largely for chronic pain -- is a key driver of America’s drug-overdose epidemic. The guideline will give physicians and patients the information they need to make more informed decisions about treatment."
Among the 12 recommendations in the guideline, three principles look to improve patient care:
- Non-opioid therapy is preferred for chronic pain outside of active cancer, palliative care and end-of-life care.
- When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
- Physicians should always exercise caution when prescribing opioids and monitor all patients closely.
- On March 15, the CDC issued its final guideline for prescribing opioids for chronic pain.
- The recommendations cover initiating or continuing opioid therapy for chronic pain, including drug selection, dosage, duration of treatment and follow-up, as well as risk assessment and addressing possible harms of opioid use.
- Although an AAFP representative participated on the team that developed the guideline, the Academy won't decide whether or not to endorse the document until its own review team assesses the changes from the draft version to the final guideline.
The recommendations cover initiating or continuing opioid therapy for chronic pain, including drug selection, dosage, duration of treatment and follow-up, as well as risk assessment and addressing possible harms of opioid use.
To complement the guideline, the CDC also has developed materials(www.cdc.gov) to assist physicians with implementing the recommendations including a fact sheet, checklist and posters.
Changes Following Public Comments
To develop the guideline, the CDC reviewed the best available scientific evidence, worked with experts (including Robert Rich, M.D., chair of the AAFP Commission on Health of the Public and Science and the AAFP's representative on the AMA Task Force to Reduce Opioid Abuse, who participated on the CDC's Core Expert Group that helped create the guideline) and reviewed and addressed comments on the draft guideline from the public and partner organizations.
The AAFP offered its comments in a letter(3 page PDF) back in January when the draft version of the guideline was released for public comment.
During a CDC call March 15 with its partners, including the AAFP, Amy Peeples, deputy director for the CDC's National Center for Injury Prevention and Control, said that guideline authors made some changes to the final guidance based on feedback to the draft version from the comments posted and recommendations from the Office of Public Health Preparedness and Response's Board of Scientific Counselors.
First, language was added to highlight patient-centered principles and the relationship between physician and patient. "We acknowledge that primary care professionals work within team-based care, so the recommendations promote collaborative working relationships with other (health care professionals)," she said.
Second, language was modified to indicate that physicians should carefully reassess evidence and individual benefits and risks when considering increasing dosage to greater than 50 morphine milligram equivalents (MME) per day and should avoid or carefully justify increasing dosage to greater than 90 MME per day. "This also improves the flexibility of what (physicians) can do at greater than 90 MME … rather than generally avoiding dosages at this level," Peeples said.
Finally, language was changed to indicate that 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," the guideline said. "Three days or less will often be sufficient; more than seven days will rarely be needed."
"This language change improves the flexibility of the number of days indicated for opioid use that usually should be sufficient for acute pain," Peeples said.
The CDC said it will continue to work with states, communities and prescribers to prevent opioid misuse and overdose by tracking and monitoring the epidemic and helping states scale up effective prevention and treatment programs. The agency also plans to continue to improve patient safety by equipping health care professionals with data, tools and guidance so they can make informed treatment decisions.
After the draft guideline was released, the Academy conducted a peer review of the document, examining its methodology and evidence base and assessing the recommendations made.
At that time, the AAFP agreed with some of those recommendations but expressed concerns about others stemming from the methodology used and a lack of supporting evidence.
In January, Jennifer Frost, M.D., medical director of the AAFP Health of the Public and Science Division, told AAFP News that family physicians may wish to consider a number of the recommendations for use in their practices. But, she noted, there just isn't a lot of high-quality clinical evidence available to support all 12.
"Literature review of available research has repeatedly revealed a paucity of research regarding best management options for acute and chronic pain, a lack of good-quality evidence pro or con regarding the use of opioids for pain and a lack of good-quality evidence for how to implement the use of opioids when a decision is made to prescribe opioids for pain control," she said.
As such, the CDC said it is dedicated to working with partners to improve the evidence base and will refine the recommendations as new research becomes available.
And although an AAFP representative participated on the team that developed the guideline, the Academy won't decide whether or not to endorse the document until its review team assesses the changes from the draft version to the final guideline.
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