Target Audience (click to view)
This activity is designed to meet the needs of physicians and nurses.
Learning Objectives(click to view)
Upon completion of the educational activity, participants should be able to:
- Review the need for guidance on the prescribing of opioids for patients with chronic pain
- Describe the CDC’s 2016 guideline on prescribing opioids for chronic pain.
Method of Participation(click to view)
Release Date: 5/18/2017
Expiration Date: 5/18/2018
Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation. A statement of credit will be available upon completion of an online evaluation/claimed credit form at akhcme.com/akhcme/lessons/32. You must participate in the entire activity to receive credit. If you have questions about this CME/CE activity, please contact AKH Inc. email@example.com.
Credit Available(click to view)
CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s. AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.
AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
NCCPA accepts AMA PRA Category 1 Credit™ from organizations accredited by ACCME.
AKH Inc., Advancing Knowledge in Healthcare is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity is awarded 0.5 contact hours.
Commercial Support(click to view)
There is no commercial support for this activity.
Disclosures(click to view)
It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.
Disclosure of Unlabeled Use & Investigational Product(click to view)
This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer(click to view)
This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.
Faculty & Credentials(click to view)
Complete the Post Test(click to view)
Recent estimates show that more than 11% of adults in the United States experience chronic pain, and clinical guidelines indicate that these patients receive appropriate pain treatment only after carefully considering the benefits and risks of drug options. Opioids are commonly prescribed for pain, with about 3% to 4% of U.S. adults being prescribed these agents for long term duration. While these medications can be effective when used for shorter durations, fewer studies have rigorously assessed the long-term benefits of opioids for pain lasting longer than 3 months.
“Opioid use presents a serious public health risk, with data showing that the number of deaths relating to opioid use quadrupled from 1999 to 2010,” says Deborah Dowell, MD, MPH. In 2013, about 1.9 million people abused or were dependent on prescription opioid pain medications. This has led many clinicians, especially those in primary care, to have increasing concerns about opioid pain medication misuse.
A Welcome Update
In 2016, the CDC released its first guideline for prescribing opioids for chronic pain that is intended for use by primary care and family physicians, internists, nurse practitioners, and physician assistants who treat adults (aged 18 and older) with chronic pain in the outpatient setting. Published in the Morbidity and Mortality Weekly Report and available for free at www.cdc.gov, the guideline is intended for use outside of active cancer treatment, palliative care, and end-of-life care. Some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians or dentists.
A key goal of the guideline is to improve communication between clinicians and patients about the risks and benefits of opioids for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy. “Clinicians need to balance the risks and benefits for each patient when considering the use of opioids,” says Dr. Dowell, who was lead author of the CDC’s guideline. The recommendations are voluntary standards that were based on emerging evidence from observational studies or randomized clinical trials.
The 2016 guideline includes 12 overarching recommendations, one of the most important being that non-opioid therapies are preferred treatments for chronic pain (Table). “A key overarching theme is to do no harm,” Dr. Dowell says. Before starting opioids, clinicians are recommended to establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks.
Dr. Dowell also says it is critical to prescribe the lowest effective dose possible whenever opioids are used. “Clinicians also need to carefully reassess benefits and risks of opioids when considering increasing the dosage,” she says. “Doctors should evaluate benefits and harms of starting opioids within 1 to 4 weeks of initiating these medications. When continuing patients on opioid therapy, physicians should monitor patients periodically, at least every 3 months, and more frequently in some cases.” The CDC adds that clinicians should review prescription drug monitoring program data for high-risk combinations or dosages.
Management plans to mitigate risks are also recommended by the CDC. Such plans should consider offering naloxone when patients are at increased risk for opioid overdose, such as patients with a history of overdose or substance use disorder, higher opioid dosages, or concurrent benzodiazepine use.
When prescribing opioids for chronic pain, the CDC recommends using urine drug testing before starting these drugs and retesting urine at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs. For patients with opioid use disorder, clinicians should offer or refer patients for evidence-based treatments, such as medication-assisted treatment with buprenorphine or methadone, and arrange follow-up care.
The CDC intends to work with federal partners and payers to evaluate payment reform and healthcare delivery models that could improve patient health and safety. Such strategies might include:
♦ Strengthening coverage for non-pharmacologic treatments, appropriate urine drug testing, and medication-assisted treatment.
♦ Reimbursing time for patient counseling.
♦ Developing payment models that improve access to interdisciplinary, coordinated care.
The CDC will revisit the guideline to determine if evidence gaps have been addressed to warrant an update and revise recommendations accordingly. “Research is needed to improve the current understanding of which types of pain, specific diseases, and patients are most likely benefit and/or be harmed from opioid therapies,” says Dr. Dowell. “Future research should also evaluate and estimate the cost-benefit of non-opioid and multidisciplinary pain interventions. New strategies for identifying and mitigating risks with opioids are also needed to improve patient and public health outcomes.”
Deborah Dowell, MD, MPH, has indicated to Physician’s Weekly that she has or has had no financial interests to report.
Readings & Resources (click to view)
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016 Mar 15 [Epub ahead of print]. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2503508.
Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain. 2015;16:769-780.
Gregorian RS Jr, Gasik A, Kwong WJ, Voeller S, Kavanagh S. Importance of side effects in opioid treatment: a trade-off analysis with patients and physicians. J Pain. 2010;11:1095-1108.
Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. American Pain Society and American Academy of Pain Medicine. Available at: http://americanpainsociety.org/uploads/education/guidelines/chronic-opioid-therapy-cncp.pdf.