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Existing guidelines vary in recommendations, and primary care providers say they receive insufficient training in prescribing opioid pain relievers. It is important that patients receive appropriate pain treatment, and that the benefits and risks of treatment options are carefully considered.
In 2012, health care providers wrote 259 million prescriptions for opioid pain relievers – enough for every American adult to have a bottle of pills.1
Prescription opioid sales in the United States have increased by 300% since 1999,2 but there has not been an overall change in the amount of pain Americans report.3,4
Almost 2 million Americans, age 12 or older, either abused or were dependent on opioid pain relievers in 2013.5
In 2013, more than 16,000 people died in the United States from overdose related to opioid pain relievers, four times the number in 1999.6
Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible.
Determining when to initiate or continue opioids for chronic pain outside end-of-life care
1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks.
2. Before starting long-term opioid therapy, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
3. Before starting and periodically during opioid therapy, providers should discuss with patients risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
Opioid selection, dosage, duration, follow-up, and discontinuation
4. When starting opioid therapy, providers should prescribe short-acting opioids instead of extended-release/long-acting opioids.
5. When opioids are started, providers should prescribe the lowest possible effective dosage. Providers should implement additional precautions when increasing dosage to > 50 MME/day and should avoid increasing dosages to > 90 MME/day.
6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of short-acting opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days will usually be sufficient for non-traumatic pain not related to major surgery.
7. Providers should evaluate patients within 1 to 4 weeks of starting long-term opioid therapy or of dose escalation to assess benefits and harms of continued opioid therapy. Providers should evaluate patients receiving long-term opioid therapy every 3 months or more frequently for benefits and harms of continued opioid therapy. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids when possible.
Assessing risk and addressing harms of opioid use
8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid-related harms are present.
9. Providers should review the patient’s history of controlled substance prescriptions using state PDMP data to determine whether the patient is receiving excessive opioid dosages or dangerous combinations that put him/her at high risk for overdose. Providers should review PDMP data when starting opioid therapy and periodically during long-term opioid therapy (ranging from every prescription to every 3 months).
10. Providers should use urine drug testing before starting opioids for chronic pain and consider urine drug testing at least annually in all patients on long-term opioid therapy to assess for prescribed medications as well as other controlled substances and illicit drugs.
11. Providers should avoid prescribing of opioid pain medication and benzodiazepines concurrently whenever possible. Recommendation should include other classes of drugs that increase risk when combined with opioids (e.g., muscle relaxants, sedatives, hypnotics, sedative-hypnotics, CNS depressants, psychoactives, atypical antipsychotics, stimulants, OTC sleep medications).
12. Providers should offer or arrange evidence-based treatment (usually opioid agonist treatment in combination with behavioral therapies) for patients with opioid use disorder.