Please note: An erratum has been published for this report. To view the erratum, please. This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1 when to initiate or continue opioids for chronic pain; 2 opioid selection, dosage, duration, follow-up, and discontinuation; and 3 assessing risk and addressing harms of opioid use.
CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation GRADE framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee.
Cdc guideline for prescribing opioids for chronic pain — united states,
It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. Opioids are commonly prescribed for pain. Inhealth care providers wrote million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills 2.
Opioid prescriptions per capita increased 7. Rates of opioid prescribing vary greatly across states in ways that cannot be explained by the underlying health status of the population, highlighting the lack of consensus among clinicians on how to use opioid pain medication 2. Prevention, assessment, and treatment of chronic pain are challenges for health providers and systems. Pain might go unrecognized, and patients, particularly members of racial and ethnic minority groups, women, the elderly, persons with cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment 4.
Patients can experience persistent pain that is not well controlled.
There are clinical, psychological, and social consequences associated with chronic pain including limitations in complex activities, lost work productivity, reduced quality of life, and stigma, emphasizing the importance of appropriate and compassionate patient care 4. Patients should receive appropriate pain treatment based on a careful consideration of the benefits and risks of treatment options.
Chronic pain can be the result of an underlying medical disease or condition, injury, medical treatment, inflammation, or an unknown cause 4. Estimates of the prevalence of chronic pain vary, but it is clear that the of persons experiencing chronic pain in the United States is substantial.
Based on a survey conducted during — 7the overall prevalence of common, predominantly musculoskeletal pain conditions e. Most recently, analysis of data from the National Health Interview Study showed that Clinicians should consider the full range of therapeutic options for the treatment of chronic pain. However, it is hard to estimate the of persons who could potentially benefit from opioid pain medication long term. On the basis of data available from health systems, researchers estimate that 9. Opioid pain medication use presents serious risks, including overdose and opioid use disorder.
From tomore thanpersons died from overdose related to opioid pain medication in the United States In the past decade, while the death rates for the top leading causes of Kenny v xanax such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly Sales of opioid pain medication have increased in parallel with opioid-related overdose deaths Although clinical criteria have varied over time, opioid use disorder is a problematic pattern of opioid use leading to clinically ificant impairment or distress.
This disorder is manifested by specific criteria such as unsuccessful efforts to cut down or control use and use resulting in social problems and a failure to fulfill major role obligations at work, school, or home Having a history of a prescription for an opioid pain medication increases the risk for overdose and opioid use disorder 22 — 24highlighting the Kenny v xanax of guidance on safer prescribing practices for clinicians.
For example, a recent study of patients aged 15—64 years receiving opioids for chronic noncancer pain and followed for up to 13 years revealed that one in patients died from opioid-related overdose at a median of 2. This guideline provides recommendations for the prescribing of opioid pain medication by primary care clinicians for chronic pain i.
Although the guideline does not focus broadly on pain management, appropriate use of long-term opioid therapy must be considered within the context of all pain management strategies including nonopioid pain medications and nonpharmacologic treatments.
The guideline is intended to ensure that clinicians and patients consider safer and more effective treatment, improve patient outcomes such as reduced pain and improved function, and reduce the of persons who develop opioid use disorder, overdose, or experience other adverse events related to these drugs.
The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations.
Clinicians should consider the circumstances and unique needs of each patient when providing care. Kenny v xanax care clinicians report having concerns about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction, and report insufficient training in prescribing opioids Across specialties, physicians believe that opioid pain medication can be effective in controlling pain, that addiction is a common consequence of prolonged use, and that long-term opioid therapy often is overprescribed for patients with chronic noncancer pain These attitudes and beliefs, combined with increasing trends in opioid-related overdose, underscore the need for better clinician guidance on opioid prescribing.
Clinical practice guidelines focused on prescribing can improve clinician knowledge, change prescribing practices 28and ultimately benefit patient health. Professional organizations, states, and federal agencies e. Existing guidelines share some common elements, including dosing thresholds, cautious titration, and risk mitigation strategies such as using risk assessment tools, treatment agreements, and urine drug testing.
However, there is considerable variability in the specific recommendations e. Most guidelines, especially those that are not based on evidence from scientific studies published in or later, also do not reflect the most recent scientific evidence about risks related to opioid dosage. This CDC guideline offers clarity on recommendations based on the most recent scientific evidence, informed by expert opinion and stakeholder and public input.
Scientific research has identified high-risk prescribing practices that have contributed to the overdose epidemic e. Using guidelines to address problematic prescribing has the potential to optimize care and improve patient safety based on evidence-based practice 28as well as reverse the cycle of opioid pain medication misuse that contributes to the opioid overdose epidemic.
This guideline is intended for primary care clinicians e. Prescriptions by primary care clinicians for nearly half of all dispensed opioid prescriptions, and the growth in prescribing rates among these clinicians has been above average 3.
Primary care clinicians include physicians as well as nurse practitioners and physician assistants. Although the focus is on primary care clinicians, because clinicians work within team-based care, the recommendations refer to and promote integrated pain management and collaborative working relationships with other providers e.
Although the transition from use of opioid therapy for acute pain to use for chronic pain is hard to predict and identify, the guideline is intended to inform clinicians who are considering prescribing opioid pain medication for painful conditions that can or have become chronic. For this guideline, palliative care is defined in a manner consistent with that of the Institute of Medicine as care that provides relief from pain and other symptoms, supports quality of life, and is focused on patients with serious advanced illness.
Palliative care can begin early in the course of treatment for any serious illness that requires excellent management of pain or other distressing symptoms End-of-life care is defined as care for persons with a terminal illness or at high risk Kenny v xanax dying in the near future in hospice care, hospitals, long-term care settings, or at home. Patients within the scope of this guideline include cancer survivors with chronic pain who have completed cancer treatment, are in clinical remission, and are under cancer surveillance only. The guideline is not intended for patients undergoing active cancer treatment, palliative care, or end-of-life care because of the unique therapeutic goals, ethical considerations, opportunities for medical supervision, and balance of risks and benefits with opioid therapy in such care.
The recommendations address the use of opioid pain medication in certain special populations e. The available evidence concerning the benefits and harms of long-term opioid therapy in children and adolescents is limited, and few opioid medications provide information on the label regarding safety and effectiveness in pediatric patients. However, observational research shows ificant increases in opioid prescriptions for pediatric populations from to 36and a large proportion of adolescents are commonly prescribed opioid pain medications for conditions such as headache and sports injuries e.
Misuse of opioid pain medications in adolescence strongly predicts later onset of heroin use Thus, risk of opioid medication use in pediatric populations is of Kenny v xanax concern. Additional clinical trial and observational research is needed, and encouraged, to inform development of future guidelines for this critical population. The recommendations are not intended to provide guidance on use of opioids as part of medication-assisted treatment for opioid use disorder.
Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists, but use in these settings or by other specialists is not the focus of Kenny v xanax guideline. This method specifies the systematic review of scientific evidence and offers a transparent approach to grading quality of evidence and strength of recommendations. This hierarchy reflects degree of confidence in the effect of a clinical action on health outcomes. The include type 1 evidence randomized clinical trials or overwhelming evidence from observational studiestype 2 evidence randomized clinical trials with important limitations, or exceptionally strong evidence from observational studiestype 3 evidence observational studies or randomized clinical trials with notable limitationsand type 4 evidence clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations.
Type of evidence is categorized by study de as well as limitations in study de or implementation, imprecision of estimates, variability in findings, indirectness of evidence, publication bias, magnitude of treatment effects, dose-response gradient, and a constellation of plausible biases that could change observations of effects.
Type 1 evidence indicates that one can be very confident that the true effect lies close to that of the estimate of the effect; type 2 evidence means that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different; type 3 evidence means that confidence in the effect estimate is Kenny v xanax and the true effect might be substantially different from the estimate of the effect; and type 4 evidence indicates that one has very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of the effect 47 When no studies are present, evidence is considered to be insufficient.
Four major factors determine the category of the recommendation: the quality of evidence, the balance between desirable and undesirable effects, values and preferences, and resource allocation cost. Category A recommendations apply to all persons in a specified group and indicate that most patients should receive the recommended course of action. Category B recommendations indicate that there should be individual decision making; different choices will be appropriate for different patients, so clinicians must help patients arrive at a decision consistent with patient values and preferences, and specific clinical situations According to the GRADE methodology, a particular quality of evidence does not necessarily imply a particular strength of recommendation 48 — Category A recommendations can be made based on type 3 or type 4 evidence when the advantages of a clinical action greatly outweigh the disadvantages based on a consideration of benefits and harms, values and preferences, and costs.
Category B recommendations are made when the advantages and disadvantages of a clinical action are more balanced. GRADE methodology is discussed extensively elsewhere 47 The U. The coverage requirements went into effect September 23, Similar requirements are in place for vaccinations recommended by ACIP, Kenny v xanax do not exist for other recommendations made by CDC, including recommendations within this guideline.
A ly published systematic review sponsored by the Agency for Healthcare Research and Quality AHRQ on the effectiveness and risks of long-term opioid treatment of chronic pain 1452 initially served to directly inform the recommendation statements. This systematic clinical evidence review addressed the effectiveness of long-term opioid therapy for outcomes related to pain, function, and quality of life; the comparative effectiveness of different methods for initiating and titrating opioids; the harms and adverse events associated with opioids; and the accuracy of risk-prediction instruments and effectiveness of risk mitigation strategies on outcomes related to overdose, addiction, abuse, or Kenny v xanax.
For the current guideline development, CDC conducted additional literature searches to update the evidence review to include more recently available publications and to answer an additional clinical question about the effect of opioid therapy for acute pain on long-term use. As identified in the AHRQ-sponsored clinical evidence review, the overall evidence base for the effectiveness and risks of long-term opioid therapy is low in quality per the GRADE criteria.
Thus, contextual evidence is needed to provide information about the benefits and harms of nonpharmacologic and nonopioid pharmacologic therapy and the epidemiology of opioid pain medication overdose and inform the recommendations. Further, as elucidated by the GRADE Working Group, supplemental information on clinician and patient values and preferences and resource allocation can inform judgments of benefits and harms and be helpful for translating the evidence into recommendations. CDC conducted a contextual evidence review to supplement the clinical evidence review based on systematic searches of the literature.
CDC constructed narrative summaries of this contextual evidence and used the information to support the clinical recommendations. On the basis of a review of the clinical and contextual evidence review methods are described in more detail in subsequent sections of this reportCDC drafted recommendation statements focused on determining when to initiate or continue opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use.
CDC sought the input of experts to assist in reviewing the evidence and providing perspective on how CDC used the evidence to develop the draft recommendations.
Concomitant overdosing of other drugs in patients with paracetamol poisoning
CDC identified representatives from leading primary care professional organizations to represent the audience for this guideline. Finally, CDC identified state agency officials and representatives based on their experience with state guidelines for opioid prescribing that were developed with multiple agency stakeholders and informed by scientific literature and existing evidence-based guidelines. Prior to their participation, CDC asked potential experts to reveal possible conflicts of interest such as financial relationships with industry, intellectual preconceptions, or ly stated public positions.
Experts could not serve if they had conflicts that might have a direct and predictable effect on the recommendations. CDC excluded experts who had a financial or promotional relationship with a company that makes a product that might be affected by the guideline.
CDC reviewed potential nonfinancial conflicts carefully e.