Safe Prescribing
Chronic pain is common, and treatment can be challenging for healthcare providers. Follow these safe prescribing guidelines.
1. Begin with alternative treatment options.
Opioids should not be the first-line or routine therapy for chronic pain. Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. See alternative pain treatment for additional ideas.
2. Make sure the benefits outweigh the risks.
Clinicians should consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Avoid prescribing opioid medication and benzodiazepines concurrently whenever possible.
3. Set realistic goals with patients.
Before initiating opioid therapy for chronic pain, determine how the effectiveness of the treatment will be evaluated and establish treatment goals for pain relief and function. Discuss known risks and realistic benefits of opioid therapy as well as patient and clinician responsibilities for managing therapy.
4. Start low and go slow.
When starting opioid therapy for chronic pain, prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids, and begin with the lowest effective dosage. Dosages at or above 50 MME/day increase risks for overdose by at least 2x the risk at <20 MME/day.
When prescribing opioids for acute pain, prescribe the lowest effective dose of immediate-release opioids and no more than needed for the expected duration of pain severe enough to require opioids. Note that 3 days or less will often be sufficient, and 7 days are rarely needed.
For more information, download the CDC’s Calculating Total Daily Dose of Opioids for Safer Dosage.
5. Recommend having Naloxone on hand.
It’s hard to believe, but 90% of overdose deaths are accidental. If you have patients who would benefit from short-term use of opioids, make sure they understand the risk. Talk with them and their families about the importance of having Naloxone on hand. Explain that Naloxone is a simple nasal spray that does not provide a high, is not addicting, and can save a life.
6. Monitor.
Follow-up regularly to reassess progress and consider how opioid therapy will be discontinued if benefits do not outweigh the risks. If opioid therapy is discontinued, taper slowly enough to minimize opioid withdrawal: begin with a decrease of 10% per week. Use urine testing before starting opioid therapy and consider urine testing at least annually to assess for prescribed medications as well as other controlled prescription and illicit drugs.
Resources:
Read the full CDC Guideline for Prescribing Opioids for Chronic Pain
Download the CDC Checklist for Prescribing Opioids for Chronic Pain
Visit the CDC Opioid Overdose Website for more information on Opioids.