CDC Pain Management Guidelines March 2016

What is the purpose of the new guideline?
The guideline helps providers make informed decisions about pain treatment for patients 18 and older in primary care settings. The recommendations focus on the use of opioids in treating chronic pain—pain lasting longer than three months or past the time of normal tissue healing. The guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

Opioids pose a risk to all patients. The guideline encourages providers to implement best practices for responsible prescribing.

Use nonopioid therapies

Use nonpharmacologic therapies (such as exercise and cognitive behavioral therapy) and nonopioid pharmacologic therapies (such as anti-inflammatories) for chronic pain. Don’t use opioids routinely for chronic pain. When opioids are used, combine them with nonpharmacologic or nonopioid pharmacologic therapy, as appropriate, to provide greater benefits.

Start low and go slow

When opioids are used, prescribe the lowest possible effective dosage and start with immediate-release opioids instead of extended-release/long-acting opioids. Only provide the quantity needed for the expected duration of pain.

Follow-up

Regularly monitor patients to make sure opioids are improving pain and function without causing harm. If benefits do not outweigh harms, optimize other therapies and work with patients to taper or discontinue opioids, if needed.

What’s included in the guideline?
The guideline addresses patient-centered clinical practices including conducting thorough assessments, considering all possible treatments, closely monitoring risks, and safely discontinuing opioids. The three main focus areas in the guideline include:

Determining when to initiate or continue opioids for chronic pain
Selection of non-pharmacologic therapy, non-opioid pharmacologic therapy, opioid therapy
Establishment of treatment goals
Discussion of risks and benefits of therapy with patients
Opioid selection, dosage, duration, follow-up and discontinuation
Selection of immediate-release or extended-release and long-acting opioids
Dosage considerations
Duration of treatment
Considerations for follow-up and discontinuation of opioid therapy
Assessing risk and addressing harms of opioid use
Evaluation of risk factors for opioid-related harms and ways to mitigate/reduce patient risk
Review of prescription drug monitoring program (PDMP) data
Use of urine drug testing
Considerations for co-prescribing benzodiazepines
Arrangement of treatment for opioid use disorder

What’s new in the CDC Guideline?

Dosage Recommendations

The dosage recommendations for exercising caution are lower than older opioid prescribing guidelines. Higher doses of opioids are associated with higher risk of overdose and death—even relatively low doses (20-50 morphine milligram equivalents (MME) per day) increase risk.

Assessing Risks and Harms

Previous guidelines focused safety precautions on “high risk patients,” however, opioids pose risk to all patients, and currently available tools cannot rule out risk for abuse or other serious harm. The CDC guideline provides recommendations on providing safer care for all patients. The guideline also encourages use of recent technological advances, such as state prescription drug monitoring programs.

Monitoring and Discontinuing

The guideline provides more specific recommendations compared to previous guidelines on monitoring and discontinuing opioids when risks and harms outweigh benefits