CDC Clinical Practice Guidelines for Prescribing Opioids for Pain
Recommendation 3: 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. Recommendation 4: When opioids are initiated for opioid-naïve 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 opioids 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. Recommendation 5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing 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 or, if warranted based on the individual circumstances of the patient, 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. Recommendation 6: 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. Recommendation 7: 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. Recommendation 8: 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. Clinicians should work with patients to incorporate into the management plan strategies to mitigate the risk, including offering naloxone. Recommendation 9: When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose. Recommendation 10: When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances. Recommendation 11: Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether the benefits outweigh the risks of concurrent prescribing of opioids and other central nervous system depressants. Recommendation 12: Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.
Selecting opioids and determining dosages
Deciding the duration of initial opioid prescriptions and conducting follow-up
Assessing risk and addressing potential harms of opioid use
Note : Dowell, et al., 2022.
Healthcare Consideration: State boards of nursing are an excellent source of information for NPs on how state laws and regulations impact practice. NPs and other prescribers must know all the details about advanced practice in their state— from signature authority to the number of CE hours required for licensure. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP)
All states maintain a prescription drug monitoring program (PDMP) for controlled substances to address overprescribing opioids and other controlled substances. Missouri was the last state to create a statewide prescription drug monitoring program with State Bill 63 (SB63, 2021). Prescription drug monitoring programs are a statewide electronic database that tracks all controlled substance prescriptions. State requirements for using PDMPs while prescribing controlled substances vary substantially; however, the White House Office of National Drug Control Policy and the CDC recommend creating and
utilizing these programs when prescribing controlled substances, especially opioids. In addition, the CDC's National Center for Injury Prevention and Control is updating the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain (CDC, 2022a; Dowell et al., 2016). PDMPs collect controlled substance prescription data from retail pharmacies (in-state, mail order, Internet), hospitals dispensing to emergency department patients (dispensing >48-hour supply), clinicians dispensing controlled substances from an office, and Department of Veterans Affairs pharmacies. Prescription data
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