CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Dowell, Deborah; Haegerich, Tamara M.; Chou, Roger

doi:10.15585/mmwr.rr6501e1er

Cited by 698 publications

(1,066 citation statements)

References 179 publications

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“…The increasing risk of long-term use even at low cumulative doses supports the CDC recommendation of limiting therapy to 3-7 days for most patients. 24 Considerable attention has been focused on the high-risk attributes of patients receiving opioids, and less attention has been given to high-risk characteristics of initial opioid prescribing patterns. Our data suggest the value of attention to high-risk prescribing, over which clinicians have greater control.…”

Section: Discussionmentioning

confidence: 99%

Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study

et al. 2016

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BACKGROUND: Long-term efficacy of opioids for noncancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use. OBJECTIVE: To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients. DESIGN: Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges. PARTICIPANTS: Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients. MAIN MEASURES: Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation (Binitiation month^). Outcome: Proportion of patients with six or more opioid fills during the subsequent year (Blong-term users^). KEY RESULTS: There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.CONCLUSIONS: Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

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Section: Discussionmentioning

confidence: 99%

Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study

et al. 2016

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“…This is encouraging given that clinical practice guidelines recommend referral to SUD treatment, when indicated, for patients on LTOT and for those who discontinue LTOT. 4,14 It is unclear what proportion of the patients who were not referred for SUD treatment (1) would have benefitted from a referral, (2) were deemed by their clinicians not to need this treatment, or (3) received some SUD treatment within the primary care setting. These data suggest that there may be opportunities to improve rates of SUD treatment referral following LTOT discontinuation.…”

Section: Discussionmentioning

confidence: 99%

“…3 To reduce opioid-related misuse and adverse events such as overdose and death, clinical guidelines recommend close monitoring of patients for aberrant behaviors using tools such as urine drug tests (UDTs) or querying state prescription drug-monitoring databases. 4,5 Evidence of high-risk behaviors, such as UDTs that are positive for illicit or non-prescribed controlled substances, may lead to discontinuation of long-term opioid therapy (LTOT). 6 Among a national sample of patients who were discontinued from LTOT, 37% were discontinued because of an aberrant UDT.…”

Section: Introductionmentioning

confidence: 99%

Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test

et al. 2017

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BACKGROUND:It is unclear whether substance use disorder (SUD) treatment is offered to, or utilized by, patients who are discontinued from long-term opioid therapy (LTOT) following aberrant urine drug tests (UDTs). OBJECTIVE: To describe the proportion of patients who were referred to, and engaged in, SUD treatment following LTOT discontinuation and to examine differences in SUD treatment referral and engagement based on the substances that led to discontinuation. DESIGN: From a sample of 600 patients selected from a national cohort of Veterans Health Administration patients who were discontinued from LTOT, we used manual chart review to identify 169 patients who were discontinued because of a UDT that was positive for alcohol, cannabis, or other illicit or non-prescribed controlled substances. MAIN MEASURES: We extracted sociodemographic, clinical, and health care utilization data from patients' electronic medical records. KEY RESULTS: Forty-three percent of patients (n = 73) received an SUD treatment referral following LTOT discontinuation and 20% (n = 34) engaged in a new episode of SUD treatment in the year following discontinuation. Logistic regression models controlling for sociodemographic and clinical variables demonstrated that patients who tested positive for cannabis were less likely than patients who tested positive for non-cannabis substances to receive referrals for SUD treatment (aOR = 0.44, 95% CI = 0.23-0.84, p = 0.01) or engage in SUD treatment (aOR = 0.42, 95% CI = 0.19-0.94, p = 0.04). Conversely, those who tested positive for cocaine were more likely to receive an SUD treatment referral (aOR = 3.32, 95% CI = 1.57-7.06, p = 0.002) and engage in SUD treatment (aOR = 2.44, 95% CI = 1.00-5.96, p = 0.05) compared to those who did not have a cocaine-positive UDT. CONCLUSIONS: There may be substance-specific differences in clinician referrals to, and patient engagement in, SUD treatment. This suggests a need for more standardized implementation of clinical guidelines that recommend SUD care, when appropriate, following LTOT discontinuation.KEY WORDS: long-term opioid therapy; chronic pain; substance use treatment; physician referral.

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“…Recommendations regarding acute pain management in patients being treated with buprenorphine are largely based on expert opinion. Treatment options include [32][33][34] :…”

Section: Clinical Example: Patient On Medication-assisted Therapymentioning

confidence: 99%

“…If it is believed necessary to provide opioid medication at discharge it should only be provided for a short period: 3 to 7 days. 35 Patients with OUD should be referred for addiction treatment, including MAT, and should be educated on harm-reduction strategies, including safe injecting, obtaining clean needles, and recognizing, avoiding, and treating opioid overdose. Prescribing intranasal naloxone should be strongly considered for patients with OUD and for patients who are taking more than 50 mg oral morphine equivalents for chronic pain.…”

Section: Discharge Planning and Managementmentioning

confidence: 99%

Acute Pain Management in Hospitalized Adult Patients with Opioid Dependence: A Narrative Review and Guide for Clinicians

Raub

Vettese

2017

Journal of Hospital Medicine

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Pain management is a core competency of hospital medicine, and effective acute pain management should be a goal for all hospital medicine providers. The prevalence of opioid use in the United States, both therapeutic and non-medical in origin, has dramatically increased over the past decade. Although nonopioid medications and nondrug treatments are essential components of managing all acute pain, opioids continue to be the mainstay of treatment for severe acute pain in both opioid-naïve and opioid-dependent patients. In this review, we provide an evidence-based approach to appropriate and safe use of opioid analgesics in treating acute pain in hospitalized patients who are opioid-dependent.

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CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Cited by 698 publications

References 179 publications

Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study

Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study

Substance Use Disorder Treatment Following Clinician-Initiated Discontinuation of Long-Term Opioid Therapy Resulting from an Aberrant Urine Drug Test

Acute Pain Management in Hospitalized Adult Patients with Opioid Dependence: A Narrative Review and Guide for Clinicians

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