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

What Do the CDC Guidelines Really Mean?

Understanding the CDC Guideline for Prescribing Opioids for Chronic Pain—Recommendations for Consideration by Primary Care Physicians for Clinical Practice
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In 2011, the Institute of Medicine estimated that 100 million adults in the United States are burdened by chronic pain, with an annual economic toll of $560 billion to $635 billion.1 More recently, estimates have increased to 126 million adults living with pain—with the aging population, that number is only expected to rise.2 Primary care physicians (PCPs) are often the very first stations along a patient’s journey to pain care, treating 52% of chronic pain patients in the US.3 In fact, management of chronic pain has largely been relegated to PCPs working in health systems not designed or equipped for chronic pain management.4

In a retrospective study of Medicare Part D prescription drug claims in 2013, PCPs were the largest prescribers of analgesics containing hydrocodone, oxycodone, codeine, and other opioids.5 Family practice physicians issued 15.3 million prescriptions, while internal medicine specialists issued 12.8 million prescriptions, nurse practitioners issued 4.1 million prescriptions, and physician assistants issued 3.1 million prescriptions.5 Unfortunately, many clinicians prescribing pain medication have little training in pain management or prescription opioids, and management of chronic pain patients within primary care centers is seen as problematic.6

In 2016, the Centers for Disease Control and Prevention (CDC) issued guidelines for PCPs who prescribe opioids.7 The CDC based its rationale on the following concerns reported by PCPs: the misuse of prescription opioids, the stress of managing chronic pain patients, the rise of addiction, and inadequate training in prescribing opioids.8 The agency’s recommendations are tailored for PCPs who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. In particular, the guidelines aim to improve communication between clinicians and their patients about the risks and benefits of opioid therapy for chronic pain, to improve the safety and effectiveness of pain treatment, and to reduce the risks associated with long-term opioid therapy. As such, the CDC issued guidelines and not legal requirements. (See Chapter 2 for interview with Jennifer Bolen, JD, about legal interpretation of guidelines).

Table 1. 12 Recommendatons from the Centers for Disease Control and Prevention for Prescribing Opioids for Chronic Pain

The guidance includes 12 main recommendations (Table 1). These may be grouped into 3 main areas: determining when to initiate or continue opioid therapy for chronic pain; the selection, dosage, duration, follow-up, and discontinuation of opioids; and how to assess and address the potential harms of opioid use.7,8

This chapter aims to interpret the main points of guidance that would relate to an opioid-naïve patient seeking treatment from a PCP for chronic noncancer pain. Such pain is prevalent and can be challenging to treat.9 Chronic pain also differs from acute pain in its involvement of central sensitization and its occasional incorporation of a neuropathic component (multimechanistic pain).10,11

Nonopioid Alternatives

One of the most crucial takeaway messages from the new CDC opioid guidelines is that nonopioid analgesics (acetaminophen or nonsteroidal anti-
inflammatory drugs (NSAIDs)) should be considered frontline treatment for opioid-naïve patients with chronic noncancer pain. Care must be taken when prescribing these agents, since they carry their own associated risks and side-effect profiles. Acetaminophen is associated with hepatoxicity at high doses, and some evidence has associated it with hypertension among selected patients.12,13 NSAIDs can provide effective pain relief but may be associated with gastrointestinal (GI) symptoms, renal, and cardiovascular complications.14-18 Nevertheless, such nonopioid analgesics should be evaluated as first-line therapy for most patients with chronic noncancer pain.

Due to maladaptive central neuronal plasticity, long-term moderate to severe pain may often incorporate a neuropathic component, which is not effectively treated by conventional nonopioid analgesics.19 Multimodal management options that include adjuvant agents, such as anticonvulsants, muscle relaxers, and antidepressants, may be considered to help alleviate multimechanistic pain.20

When treating chronic noncancer pain patients who have not yet taken opioid analgesics, providers should first take a thorough history and attempt to diagnose the underlying painful condition. Patients may be asked to pinpoint their pain sites, which may be multiple (this may be more easily done using an anatomical diagram). For each site, patients should be asked to describe how the pain feels (sharp, dull, stabbing, burning, electrical, shooting, intermittent, tingling, etc), how often it occurs (continuous or intermittent), which factors may worsen or alleviate it (such as certain movements), and whether or not it migrates. The clinician should then measure the patient’s pain using a validated pain scale, such as a visual analog scale, for each pain site.

Note that acute pain is typically associated with a known cause and clear localization, while chronic pain can be more diffuse, vague, and variable in location. Additionally, it is not unusual for a chronic pain site to be distant from the original injury or to be unassociated with any injury at all.

During this discussion, physicians should make note of whether specific factors can lessen patients’ pain. For example, patients may report finding relief with movement, stretching, exercise, heating pads, ice packs, or other interventions. This can be a good time to bring up nonpharmacological pain treatments, which can be quite effective and may include physical therapy, occupational therapy, massage, stretching, exercise (including yoga, cardiovascular, and water-based exercises), meditation, guided relaxation, and biofeedback.

Healthful eating habits, adequate sleep, and weight loss also can contribute significantly to pain relief. Music therapy, aromatherapy, acupuncture, and complementary and alternative medicine also may be included in the mix of options, although evidence in support of these techniques is less than robust. Nevertheless, clinicians should initiate a conversation with patients that encourages a frank discussion of the wide range of available approaches to pain control.

Last updated on: September 13, 2017
Continue Reading:
A Legal Interpretation of the CDC Opioid Prescribing Guidelines
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