Opioid Prescribing and Monitoring - (Second Edition)
Primary Care Models for Pain Management

What Do the CDC Guidelines Mean for Patients on Long-Term, High-Dose Opioids?

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The latest data are sobering: death by drug overdose is now the leading cause of mortality among Americans under 50 years of age. Drug overdose deaths in 2016 exceeded 59,000, or the rough equivalent of a commercial airliner crashing every day and killing everyone on board.1 This toll includes accidental overdose deaths and suicides from both illegal and prescribed opioid use; it may be exacerbated by patients’ comorbid disease or combined drugs (benzodiazepines) and alcohol use at the time of death.

In part to address the opioid overdose epidemic and promote safer use of opioids, the Centers for Disease Control and Prevention (CDC) released the CDC Guideline for Prescribing Opioids for Chronic Pain in 2016.2 The guideline is generally reasonable and conservative in its recommendations for how primary care providers (PCPs) should treat acute pain. Nevertheless, controversy has persisted over the appropriate treatment of patients with chronic pain (> 3 months) using high-dose opioids (> 90 mg morphine equivalents daily), which the CDC recommends be “carefully justified.”

Guideline Criticisms

The CDC is aiming to reduce the availability of Schedule II and III opioids, and in particular, higher-dose extended release forms, because these drugs have been associated with a higher incidence of overdose deaths. For clinicians treating chronic pain, however, the potential for a stochastically determined threshold of 90 morphine milligram equivalents (MME) to be universally applied to every case raises several important concerns.

First, some clinicians have heavily criticized use of the MME daily dose in this context.3 One major issue is the lack of a universally accepted method for opioid conversion.3 An online survey of 319 health care professionals, for example, revealed significant differences in how they determined opioid conversion to MMEs.4 While numerous references and online calculators can assist providers with such conversions, a comparison of these tools also suggested wide variability.5

Further, a narrow focus on the risks of high-dose opioids may falsely reassure providers that lower doses of opioids are safe. In fact, there is no completely safe opioid dose; an overdose can occur at any dose.2 Although the risk doubles as the dose rises from < 20 MME to between 20 and 49 MME, and the risk increases geometrically with dosage, there are no clear cutoff pinpoints when an overdose may occur in any given individual.6-8

Specifically, the MME does not take into account unique patient factors like age, drug-drug interactions, comorbidities, weight, and renal/hepatic function, to name a few.3 Note, some patients receiving higher doses of opioids may be sicker and more likely to have medical comorbidities, and therefore may be taking multiple medications, all of which contribute to risk of overdose. Likewise, pharmacogenetic polymorphism (allotypic variation) can lead to interindividual variability in drug response, which may lead to alterations in efficacy, safety, and tolerability of medications.9-10

Understanding the Risks

The CDC guidelines are not intended to limit the ability of pain specialists to prescribe beyond 90 MME.2 Even so, it is important that practitioners understand: when a high-dose opioid prescription may be appropriate, what documentation is needed to justify the medical necessity when it is, and how to manage the situation when it is not.

As pain specialists, we know that opioids can play a role in the long-term treatment of chronic pain in many cases and that high-dose opioids (> 90 MME) may be warranted on occasion. As conscientious practitioners, we certainly do not intend to cause harm or contribute to opioid use disorder. Nevertheless, we also must recognize that 65% of abused prescription opioids are accessed through a friend or family member who received that prescription from a physician.11 This all-too-common scenario should give us pause when we’re considering prescriptions that can be lethal to the opioid-naïve.

In addition, high-dose opioid prescriptions are often synonymous with long-acting preparations. These long-acting opioids place patients at increased risk for overdose, especially upon initiation.12 A high dosage and long-term duration of opioids further increase the risk for overdose and opioid use disorder.7,8,12 Increased opioid doses correlate with dose-dependent tolerance, hypogonadism, hormonal imbalances, and immune suppression.13 More than 90% of patients treated with high-dose opioids also experience side effects, such as drowsiness and constipation, the former of which is usually overcome within 2 weeks of dosage adjustment due to physical tolerance.14,15 Scherrer et al have reported that long-term opioid use generally correlates to psycho-
emotional issues, such as depression.16

Patients on long-term opioid therapy also can exhibit psychomotor impairment, which can increase their risk of falls, injuries, and traffic accidents.17,18 Some older studies, though, have shown that long-term opioid therapy does not have an adverse effect on motor vehicle response time compared to the distraction of untreated pain.19-21 Further, chronic opioid use negatively correlates with the ability of patients to return to meaningful work.22

Given that all of these issues may significantly impact a patient’s quality of life and functionality, practitioners should carefully consider the context of each patient’s psychosocial situation when prescribing high-dose and long-acting opioids. In general, we find that patients under consideration for such opioids fall into 2 categories. The first category includes patients on lower-dose therapy for whom we are considering an escalation to higher doses. The second category includes “legacy” patients already established on higher doses.

Patients Under Consideration for Dose Escalation

For the first group of patients, physicians should first reevaluate the clinical situation to see if alternative treatment options may help provide improved pain control and function. Opioids should always be used in the context of a comprehensive multimodal pain treatment program. Physical therapy, acupuncture, chiropractic treatment, biofeedback, psychological counseling, and other modalities may be available, depending on the patient.

Last updated on: September 13, 2017
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Assessment and Monitoring of Pain: Current Tools