depending upon the circumstances, including the condition that the prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of professional practice. Finally, the pharmacist must be satisfied that the prescription is consistent with CSA and DEA regulations before dispensing the controlled substance to the ultimate user (DEA, 2018c).
Healthcare Consideration: The number of drug overdose deaths increased by nearly 5% from 2018 to 2019 and has quadrupled since 1999. Over 70% of the 70,630 deaths in 2019 involved an opioid (CDC, 2021). Therefore, competence with both state and federal regulations should be maintained.
CDC CLINICAL PRACTICE GUIDELINES FOR PRESCRIBING OPIOIDS FOR PAIN
This clinical practice guidelines are intended for clinicians who are treating outpatients age >18 years with acute (duration of <1 month), subacute (duration 1–3 months), or chronic (duration >3 months) pain and excludes pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care (Dowell et al., 2022). These clinical practice
guidelines are intended to help clinicians weigh the benefits and risks of prescribing opioid pain medication for painful acute conditions (e.g., low back pain, neck pain, other musculoskeletal pain, neuropathic pain, dental pain, kidney stone pain, and acute episodic migraine), postoperative pain, and pain related to oral surgery procedures (Dowell et al., 2022).
CDC Clinical Practice Guidelines for Prescribing Opioids for Pain
Determining Whether or Not to Initiate Opioids for Pain Recommendation 1:
Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and consider opioid therapy for acute pain only if the benefits are anticipated to outweigh the risks to the patient. Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the benefits and risks of opioid therapy. Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh risks to the patient. Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the benefits and risks of opioid therapy, work with patients to establish treatment goals for pain and function, and consider how opioid therapy will be discontinued if benefits do not outweigh the risks. When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate- release opioids instead of extended-release and long-acting (ER/LA) opioids. When opioids are initiated for opioid- naive patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing them at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients. For patients already receiving opioid therapy, clinicians should carefully weigh the benefits and risks and exercise care when changing the opioid dosage. If the benefits outweigh the risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If the benefits do not outweigh the risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages. Based on the individual circumstances of the patient, clinicians should appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue, such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages. When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Clinicians should evaluate benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute or chronic pain or dosage escalation. Clinicians should regularly reevaluate the benefits and risks of continued opioid therapy with patients. Before starting and periodically during the continuation of opioid therapy, clinicians should evaluate the risk for opioid-related harms and discuss the risk with patients. In addition, clinicians should work with patients to find strategies to mitigate the risk. When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should use state prescription drug monitoring program (PDMP) data to review the patient’s history of controlled substance prescriptions to determine whether the patient is receiving opioid dosages or combinations that put them at high risk for overdose.
Recommendation 2:
Selecting Opioids and Determining Dosages Recommendation 3:
Recommendation 4:
Recommendation 5:
Deciding the Duration of Initial Opioid Prescriptions and Conducting Follow-up Recommendation 6:
Recommendation 7:
Assessing Risk and Addressing Potential Harms of Opioid Use Recommendation 8:
Recommendation 9:
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