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Hello and welcome. I am Dr George Lundberg and this is At Large at Medscape.

I love the CDC, founded as the Communicable Disease Center in 1946 near Atlanta, Georgia, to take on malaria. It has been renamed several times, most recently in 1992 as the Centers for Disease Control and Prevention, or CDC. They do so much good work. Richly recognized as expert in dealing with infectious diseases and epidemic recognition and control, the CDC has been expanded to branch out into many other important areas of medicine.

True, the CDC has taken some deserved flak in recent years from critics who have expressed concern about conflicts of interest with industry, particularly regarding HIV and some other infectious diseases, and in the political arena regarding violence and gun research. But I laud its efforts, generally, and am really pleased that they have now taken on the American prescription opioid debacle. This column has previously addressed some elements of that mess.[1,2,3]

On December 14, 2015, the CDC posted the draft guidelines. The number of invited public comments through January 15, 2016, totaled more than 4000.

The process has been elaborate, based on exhaustively referenced literature review and involving all of the major professional stakeholders. This draft is a really big deal, and if you have the time, you could plow through all of it. But here is the "skinny"—read it, apply it. It may be boring but it really matters to your daily practice. The recommendations[4] are grouped into three areas for consideration. (The evidence base and GRADE framework designations are included in the full draft document.)

The Recommendations

But before we get started, understand that I, as a physician, deplore the use of the word "provider" in all 12 recommendations. Please do not let that turn you off to the whole schmear. Pretend it says "physician" each time and read on.

Determining When to Initiate or Continue Opioids for Chronic Pain

1. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.

2. Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.

3. Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.

Opioid Selection, Dosage, Duration, Follow-up, and Discontinuation

4. When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.

5. When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to 50 morphine milligram equivalents (MME)/day or more, and should generally avoid increasing dosage to 90 MME/day or more.

6. Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most nontraumatic pain not related to major surgery.

7. Providers should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.

Assessing Risk and Addressing Harms of Opioid Use

8. Before starting and periodically during continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or higher opioid dosages (≥ 50 MME), are present.

9. Providers should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.

10. When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.*

11. Whenever possible, providers should avoid prescribing opioid pain medication for patients receiving benzodiazepines.

12. Providers should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

Did you get all of that? If you want more detail, the full draft document includes the large evidence base supporting these recommendations and a whole lot more.

Pretty much every relevant professional US organization that matters has bought into this effort. But it is all not worth a hill of beans unless you, the physician in practice, implement these recommendations for daily use.

Do it now!

That's my opinion. I am Dr George Lundberg, at large at Medscape.

*Please note the potential conflict of interest: The company of which I am the chief medical officer, CollabRx, recently merged with Medytox (a company that owns laboratories that perform drug testing) to form Rennova Health.


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