Pain is one of the most common problems affecting patients. By one estimate, 11% of Americans experience daily pain.1 Over the past two decades in the United States, opioids have been used much more often—and other treatments less often—to manage chronic pain. In the 1990s, it was hoped that opioids could relieve chronic pain as effectively as they relieve suffering at the end of life, and that they could be used safely in the long term. Physicians were encouraged to discard “opiophobia”2 and use opioids to manage chronic pain based on small, uncontrolled studies reporting low rates of addiction. Now, however, it is unclear how effective long-term opioid therapy is for managing pain.3
Because of the unique effects of opioids, including tolerance and physical dependence, the question of whether opioids relieve pain in the long term is important. Most controlled trials have evaluated their effectiveness for six weeks or less.3 Long-term opioid use is associated with significant risks, such as opioid use disorder, potentially fatal overdose, falls, motor vehicle injuries, and myocardial infarctions, and evidence shows that these risks increase with dose and duration of use.3 As many as one in four patients receiving long-term opioid therapy for noncancer pain in primary care settings has opioid use disorder.4 A recent population-based cohort study found that one out of 550 patients receiving opioid therapy for noncancer pain died from opioid-related causes at a median of 2.6 years from the first prescription.5 In patients whose dose was increased to more than 200 morphine milligram equivalents per day, 3.1% died of opioid-related causes.
Given the accumulating evidence on the risks of long-term opioid therapy and continued uncertainty about the long-term benefits, how should physicians determine whether and how to use opioids to help patients who are struggling with chronic pain? And how can they determine whether opioids are the best treatment option for patients with other conditions, such as chronic headache, neck pain, fibromyalgia, rheumatoid arthritis, osteoarthritis, diabetic neuropathy, or postherpetic neuralgia?
The Centers for Disease Control and Prevention (CDC) recently released a guideline for primary care clinicians who care for adults with chronic pain (i.e., lasting longer than three months or past the time of normal tissue healing) in outpatient settings outside of active cancer treatment, palliative care, and end-of-life care.3 This guideline is intended to help clinicians decide whether and how to prescribe opioids for chronic pain; offer safer, more effective care for patients with chronic pain; improve clinician-patient communication; and prevent opioid use disorder and opioid-related overdose. The guideline is based on a rigorous evidence review using the Grading of Recommendations Assessment, Development, and Evaluation framework6 with input from various expert groups, medical organizations, clinicians, patients, advocacy groups, state agencies, national partners, a federal advisory committee, and the general public. The guideline is summarized in this issue of American Family Physician.7 Among its 12 recommendations are the following especially important points that can help clinicians make treatment decisions for patients with chronic pain:
Nonopioid therapy is preferred for management of chronic pain. Opioids should not be used as routine therapy outside of active cancer treatment, palliative care, or end-of-life care. When opioids are used, they should be combined with other therapies to improve benefits for patients.
When opioids are used, the lowest effective dosage should be prescribed to reduce the risk of opioid use disorder and overdose.
Clinicians should use caution when prescribing opioids, closely monitor all patients receiving opioids, and continue opioid therapy only after reevaluating the patient to determine whether the benefits outweigh the risks.
The full CDC guideline is available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?scid=rr6501e1_w. We encourage you to review the available tools to help integrate the recommendations into your practice. A checklist decision aid, patient poster, and fact sheets about the use of nonopioid therapies and prescription drug monitoring programs are available at http://www.cdc.gov/drugoverdose/prescribing/resources.html. Other resources related to the opioid abuse and overdose epidemic are available at http://www.hhs.gov/opioids/health-professionals-resources/index.html. The CDC guideline and tools can help clinicians increase the use of integrated treatment approaches and provide patient-centered care for those with painful chronic conditions.
The conclusions in this report are those of the authors and do not necessarily represent the official position of the CDC.