CDC Guideline for Prescribing Opioids for Chronic Pain

Introduction
From the year 1999 to 2014, the number of prescription opioids in the USA quadrupled. However, even with such an increase, there was no evidence of a reduction of pain the patients experienced. Instead, the number of deaths that resulted from overdoses of opioids increased in the same ratio as the increase in prescription figures. The Center for Disease Control provides safety guidelines for the prescription of opioids for pain alleviation in persons aged 18 years and above, in settings outside medical care facilities such as palliative care centers, and end of life care points(CDC, 2016). This paper provides a summary of the CDC guidelines on the prescription of opioids for chronic pain relief and a regime plan for opioids as APRN.
Summary of main concepts
Determining when to start or proceed with opioids for chronic pain
1. Non-first line or routine chronic pain therapy Opioids
Chronic pain is best handled with nonpharmacologic and non-opioid therapy. Clinicians should consider having opioid treatment on the cards only if the benefits they expect to exceed the risks to the patient under treatment. In case the opioids are prescribed, they should be offered alongside nonpharmacologic therapy and non-opioid therapy, as the situation demands (Dowell, Haegerich & Chou, 2016).
2. Determine and measure the progress towards attainment of goals
Before initiating opioid therapy for chronic pain, healthcare experts should establish the goals for treatment with the patients. They should include realistic goals that will tackle the pain and function of the body. Thus, consideration should be made on how to discontinue therapy when it is realized that therapy is outweighed by the risks to the patient.
Before the onset of opioid therapy, and periodically after that, there should be an open discussion between clinicians regarding the risks involved in using a particular therapy. Realistic benefits should also be outlined. The clinician and patient responsibilities during the therapy should be discussed too (Dowell et al., 2016).
Opioid selection, dosage, duration, follow-up, and discontinuation
1. Make use of immediate-release opioids at the onset
Clinicians should only prescribe immediate-release opioids when starting opioid therapy as opposed to the extended-release ones.
2. Clinicians should stay cautious at any dosage administration and avoid raising it higher, unnecessarily.
3. Clinicians should start with the lowest effective dosage when starting to administer opioids. Caution must be exercised at any dosage. The benefits should be documented, with evidence, carefully, as the opioids are administered. The risks should also be documented if and when the dosage is increased?50 MME, and increasing dosage to ?90 morphine milligrams per day should be avoided. Otherwise, dosage titration to ?90 per day should be justified.
4. Avoid prescribing more than is needed
Opioid use, in the long term, starts with acute pain treatment regimes. When the drug is used to alleviate acute pain, healthcare experts should only prescribe the lowest immediate release dose that is effective. They should not raise the dose to higher levels that needed during the treatment span of acute pain that calls for steroid use. Three days of opioid administration should suffice in most cases. It should never go over seven days in whatever circumstances.
5. Provide a taper if the opioids are not seen to act or are harmful
Health experts should review the effect of the opioids administered in one to four weeks of escalated administration. The benefits and the side effects of the opioid prescription and therapy should be reviewed every three months or before then (Dowell et al., 2016). If the benefits are less than the harms of continuous usage of the drugs, then there should be a clear exit plan for the discontinuation of the opioids via tapering strategies to reduce them gradually.
Risk assessment and dealing with the negative effects of opioid usage
1. Identify, evaluate and assess the risks involved of opioid usage
Opioid-related harms should be assessed by clinicians first before they initiate any opioid therapy, or even during the period of the therapy. Healthcare providers should include plans for risk management, such as offering naloxone when there is a host of factors that could increase the risk. Such factors include the history of use disorders, overdose, co-occurring Benzodiazepine usage and the like are present.
2. Inspect PDMP for dangerous combinations and high doses
Healthcare staff should check the patient’s previous usage of controlled substances to make sure that they are not in danger as a result of such usage. Clinicians should make use of PDMP data when administering opioid therapy intermittently or initiating it for chronic pain cases from prescription to after every three months.
3. Conduct urine test for previous use of opioids and other dangerous combinations
Urine drug testing should be the starting point before the administration of opioid therapy. It is best if the urine drug testing is even done annually.
4. Desist from prescribing opioids alongside benzodiazepine.
The above practice should be avoided as much as possible.
5. Subject patients to Opioid use disorder treatment
Medication-assisted treatment or other evidence-based treatment should be offered to patients with complicated drug traces in their system or those with opioid use disorder or those with chronic pain.
Plan for Advanced Practice Registered Nurse (APRN)
The APRNs who handle patients experiencing pain are usually certified, nursing practitioners. Just like their family practice physicians, they do not have education relevant to how to manage pain professionally (Institute of Medicine, 2011). Indeed, over 50% of opioid prescriptions are given by healthcare workers without the expert knowledge of how to manage pain, particularly CNPs (Breuer, Cruciani, & Portenoy, 2010; Hudspeth, 2016). Such providers could encounter situations where they are forced to make decisions based on the job experience, irrespective of the vetted, and acceptable standards of care (SOCs). Such decisions could be counterproductive. There could be an opioid diversion or even an overdose that leads to death, for instance. These outcomes end up with complaints to the board of nursing (BON).
Using the Standard of Care (SoC) for APRNs
The Standard of Care provides the rubric for APRNs to effectively evaluate the management of the pain process of care in four stages
Stage 1: Physical and history assessment
In the healthcare records, the clinician should extract the interview and history of the ailment and or injury that leads to the pain. In such records, details of any mitigating interventions and comorbidities of management are normally outlined. The assessment includes details of referrals, reports of treatment, opioid abuse screening reports, PDMP reports, therapies, lab exams, Urine Drug Tests outcomes, imaging outcomes, and the like(Hudspeth, 2016). Screening tools are in common usage and relied on for accuracy.
Stage 2: Decision to subject the patient to opioid treatment
The practitioner should secure an informed document certified by the APRN and patient or their guardian. The document is evidence that the benefits and risks have been discussed with the patient or their guardian and understood (Cheatle & Savage, 2012). Opioid treatment benefits include attaining a level of wellbeing that allows a patient to carry on with basic life activities.
Stage 3: Trial of Opioids prescription
The first treatment should be regarded as a therapeutic assessment with specified goals, parameters of treatment, and determining guidelines. The dosage of opioid may increase during the trial, or even change from a given prescription drug to another. It could be from morphine, for example, to oxycodone.
Stage Four: Ongoing Treatment and Evaluation
Problems surface mostly at this stage. Due to familiarity with the patient, an APRN may drop their guard and miss out on important indications of problems. Thus, APRNs are encouraged to continue with thorough care and documentation at all stages (Hudspeth, 2016). The self-reported pain rating from the patient should be collected at each visit. An attempt to reduce or increase dosage should be made with well-documented justification for the latter.
Opioid Prescription Schedule
Acute Pain
0 - 6 weeks
Subacute Pain
6 - 12 weeks
Chronic Pain
12 weeks
Before prescribing opioids for non-operative and perioperative acute pain:
· Run a patient evaluation and document.
· Inspect the Prescription Monitoring Program (PMP) and document concerns
· A patient treatment plan should be documented
· The opioid risks should be made clear to the patient, including storage safety and disposal
Before prescribing opioids:
· Conduct and document a patient evaluation and PMP query
· Evaluate the benefits and risks of the use of opioids. Craft a plan of treatment for the patient
· Consider risks and benefits for continued opioid use. Document a patient treatment plan.
· Options such as tapering, discontinuing and or transitioning should be weighed for chronic pain treatment
· If opioid treatment is to go beyond 12 weeks, then transition to chronic pain should be documented
When treating chronic pain patients with opioids:
· Run a PMP and patient evaluation query
· Complete a patient treatment plan with objectives
· An agreement for treatment should be filled.
· Review the treatment plan periodically for high-risk checks with quarterly PMP, biannually for moderate risks, and annually for low-risk patients.
An ICD or diagnosis should always be included on all opioid-based prescriptions.
Include the diagnosis or International Classification of Disease (ICD) code on all opioid prescriptions
An APRN must always bring to the patient’s attention, their right to refuse an opioid-based prescription. Such a refusal should be documented.
Exclusions
Rules do not apply to:
· Patients pain related to cancer ailment
· Hospice, Palliative, or other end-of-life care
· Procedural pre-medications
· Inpatient hospital patients
Co-Prescribing
There shall be no opioid prescription with the medications below with no patient record documentation, consultation with other prescribers and risk discussion; whether for a care plan or for tapering Benzodiazepines
· Sedatives
· Barbiturates
· Carisoprodol
· Non-benzodiazepine hypnotics (Z drugs)
When co-prescribing opioids to a patient receiving medication-assisted treatment (MAT):
· Consult the MAT prescriber or a pain specialist
· Do not deny necessary operative treatment due to MAT
· Do not discontinue MAT without documentation
prescribe or Confirm naloxone when:
· Opioids prescription is ? 50 MED or a
· Opioids prescribed to a high-risk patient
· As clinically shown
Alternative Modalities
APRNs should outline pain management alternatives to opioids with patients and consider
· Cognitive behavior therapy
· Osteopathic manipulative treatment
· Acupuncture
· Chiropractic medicine
· Acetaminophen
· Massage therapy
· Nonsteroidal anti-inflammatory drugs
· Physical therapy
· Sleep hygiene
Consultation Requirements
· There must be consultation with a pain management specialist when prescribing 120 MED and over unless there are consultation exemptions
Patient Notification
· APRNs should offer patients with education on the safety and risks involved in opioid use. The patient should reserve the right to decline the treatment. They should also be made aware of the correct disposal options.
References
Breuer, B., Cruciani, R., & Portenoy, R. K. (2010). Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey. Southern Medical Journal, 103(8), 738-747.
CDC, (2016). CDC Guideline for Prescribing Opioids for Chronic Pain. Center for Preparedness and Response (CPR).
Cheatle, M. D., & Savage, S. R. (2012). Informed consent in opioid therapy: a potential obligation and opportunity. Journal of Pain and Symptom Management, 44(1), 105-116.
Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—the United States, 2016. Jama, 315(15), 1624-1645.
Hudspeth, R. S. (2016). Standards of care for opioid prescribing: What every APRN prescriber and investigator need to know. Journal of Nursing Regulation, 7(1), 15-20.