Slide narration: Hello, and welcome to the fourth module of the CDC series: Applying CDC's Guideline for Prescribing Opioids. In this module, we'll look at the CDC-recommended options for reducing the risks of opioids. You will have the opportunity to learn more about strategies to mitigate risk for your patients taking opioids. You will also learn about how to use results from urine drug testing (UDT), prescription drug monitoring program (PDMP) checks, and medical history and physical examinations. At the end of the module and throughout, you will be presented multiple choice knowledge checks to test your mastery of the content.
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CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016
Narration text: You may find it useful to refer to the CDC Guideline during this module. You can access, download, and print a copy of this and other helpful documents by selecting the Resources tab at any time. Some screens include a link icon which, when selected, opens additional online resources. Let's take a closer look at the navigation features of this web-based training. As you've experienced already, the Next and Back buttons enable you to move to a new screen or back to a previous screen. If either the Next or Back button is dimmed, it is disabled, and you will need to complete an action onscreen to continue. Refer to the navigation prompt located at the bottom of the screen to help you determine how to proceed. Selecting the Menu button in the upper right corner opens a list of all the topics available in the module. A selection made from the list advances the training to that topic. Pressing the open Menu tab a second time will collapse it. There is also a set of audio controls located at the bottom of the training window. Here you can pause or play the narration, control the volume, and open the text transcript for the narration if needed. Most slides, however, will not be narrated, and this set of controls will be dimmed and disabled.
Improving the way opioids are prescribed will ensure patients have access to safer, more effective chronic pain treatment while reducing opioid misuse, abuse, and overdose.
Prescription drug monitoring programs (PDMPs), urine drug testing (UDT), and patient education are important components of ensuring patient safety.
PDMPs are state-run databases that track prescriptions for controlled substances. Providers can review a patient's history of controlled substance prescriptions and determine whether the patient is receiving opioid dosages or dangerous medication combinations that put him/her at high risk of overdose. It is a valuable tool for safer opioid prescribing. State requirements vary, but CDC recommends checking the PDMP prior to every opioid prescription and at least once every three months when prescribing opioids for chronic pain.
There are some limitations to PDMP data. Providers treating patients who obtain prescriptions in multiple states may not have the ability to view the complete picture of prescription data without access to multiple state PDMPs. Medications prescribed in opioid treatment programs and in a closed program, such as Veterans Health Administration facilities, may not be listed in a state's PDMP.
UDT can provide information about drug use that is not reported by the patient. UDT results provide data regarding whether a drug is in the urine at a threshold concentration but doesn't necessarily provide data regarding whether someone is taking the opioid as prescribed.
There is a differential diagnosis for all UDT findings (expected or unexpected). Also, UDT can be tricky to interpret and might require consultation with the laboratory or local toxicologist for proper interpretation. In addition, there is the potential for false-positive or false-negative results. Lastly, not every drug of interest is included in all UDT panels.
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.
PDMPs can help to improve patient safety in multiple ways.
It allows providers to identify patients who are obtaining opioids from more than one provider and thus might be receiving high total daily dosages of opioids.
By checking your state's PDMP, you are taking an important step in the safer prescribing of opioids. States that require PDMP checks prior to prescribing show reductions in the number of patients with multiple prescribers1, 2
It identifies patients who are being prescribed other substances, such as benzodiazepines, that may increase risks associated with opioids. Please note that non-controlled substances do not appear in the PDMP, nor do medications prescribed in an opioid treatment program.
State requirements vary, but CDC recommends that providers review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.
If you find concerning information in the PDMP, do not dismiss patients from care. You should share and discuss the findings with other providers.
You should confirm the patient is aware of additional prescriptions. Also, you should discuss safety concerns with the patient, such as increased risk for respiratory depression and overdose. You can use the opportunity to provide potentially lifesaving information and interventions.
You should calculate the total morphine milligram equivalent (MME) per day to help assess the patient's overdose risk. If it is high (≥50 MME/day and especially ≥90 MME/day), consider tapering to a safer dosage, offering naloxone, and assessing for opioid use disorder.
Note: All names and addresses used in this module are entirely fictional, and any resemblance is purely coincidental.
New patient to your practice, transferring care due to insurance change
Medical history: Bilateral knee osteoarthritis diagnosed 15 years ago; Has been taking 3-4 hydrocodone/acetaminophen 10/325 mg tablets each day for the past 10 years for pain management; Rides her bicycle 2-3 times per week
No documentation of UDT is found.
Which of the following factors related to Ms. Smith's opioid therapy are particularly risky? Select all that apply.
The correct answers are A and C. Ms. Smith's PDMP data indicates she has prescriptions for opioids from multiple providers. Also, her medical records indicate that no urine drug testing has ever been performed despite her long-term opioid use.
Note: All names and addresses used in this module are entirely fictional, and any resemblance is purely coincidental.
Medical History: Low back pain; Onset 8 years ago following a motor vehicle crash; Takes extended-release morphine 45mg twice daily; Has tried physical therapy and regular exercise to help manage pain
Medications: Denies medications other than the opioids described above
Which of the following factors related to Mr. Miller's opioid therapy are particularly risky? Select all that apply.
The correct response is A, B, C, and E. Mr. Miller is receiving multiple opioid prescriptions from multiple different providers, and he did not disclose this information. Also, he is taking an unsafe high daily dosage of opioids, not even factoring in the extra prescriptions he received from his dentist and from another physician. We now know that high dosages of opioids increase the risk of overdose and development of opioid use disorder. Lastly, there is no documentation of a urine drug test despite long-term opioid use.
Incorporating nonopioid treatment modalities - including both nonopioid pharmacologic options and nonpharmacologic options like exercise - is actually an important first-line strategy to treat pain.
Patients with the following conditions are at greater risk of harm from opioids and increased risk of opioid overdose.
There is no clear clinical consensus regarding the association of opioids and the risk for developing obstructive sleep apnea syndrome. However, opioid therapy can:
Patients with renal or hepatic insufficiency can experience greater peak effect and longer duration of action for medications, thereby reducing the dose at which respiratory depression and overdose may occur. Similarly, for patients ages 65 years and older, reduced renal function and medication clearance due to age can result in a smaller therapeutic window between safe dosages and dosages associated with respiratory depression and overdose.
Patients who are older adults may experience an increased risk for falls and fractures when using opioids. Older adults also have decreased clearance of drugs which can result in accumulation of drugs to toxic levels. Cognitive impairment in older adults can increase risk for medication errors. Older adults are also more likely to have co-morbid medical conditions for which other medications are prescribed that might interact with opioids.
Prescribing opioids for pain management in pregnancy may result in additional risks to both mother and fetus. Studies have shown that opioid use during pregnancy is associated with:
In addition, opioid use during pregnancy may lead to neonatal opioid withdrawal syndrome, also called neonatal abstinence syndrome or NAS.
Patients with mental health comorbidities, such as depression and anxiety, are more likely to experience opioid use disorder and overdose than other patients. Patients with chronic pain and depression are also at elevated risk for suicide ideation and attempts.
Patients with a history of substance use disorders may be at a higher risk for opioid use disorder than other patients. Studies found that substance abuse/dependence was more prevalent among patients experiencing opioid overdose versus those not experiencing overdose.
Note: All names and addresses used in this module are entirely fictional, and any resemblance is purely coincidental.
Medical History: Right shoulder pain; Onset 7 months ago after playing tennis; Takes extended-release oxycodone 10mg twice per day; Trial of NSAIDs not effective; Currently does physical therapy to help to alleviate the pain; Not interested in surgical referral and prefers medical management of pain
Alcohol Use Disorder, in sustained remission: Diagnosed five years ago with mild alcohol use disorder; In sustained remission: has regularly participated in a 12-step program since diagnosis; No reported alcohol use since that time
Major depressive disorder: Diagnosed 12 years ago; Stably managed on sertraline 50 mg once per day; No history of suicide attempt or ideation
No documentation of UDT is found. The oxycodone prescription is confirmed by the PDMP, and no other controlled substance prescriptions are noted.
Which of the following factors related to Ms. Anderson's opioid therapy are particularly risky? Select all that apply.
The correct response is A, C, and D. She has depression and a history of alcohol use disorder which puts her at higher risk for opioid use disorder overdose, and suicidal ideation than other patients. It is important to consult with a behavioral health specialist for patients with a history of a mental health condition, particularly with a history of a suicide attempt. Lastly, there is no documentation of a urine drug test despite long-term opioid use.
There are many benefits to using UDT to mitigate patient risk when taking opioids.
UDT helps in identifying concurrent use of opioid pain medications with illicit drugs and other controlled medications, both prescribed and unprescribed, that may increase the risk for overdose when combined with opioids.
UDT provides information about drug use that is not reported by the patient.
UDT assists providers in identifying when patients are NOT taking opioids prescribed for them, which might indicate diversion or other clinically important issues such as difficulties with adverse effects that may not have been reported to the provider.
There can be limitations to using UDT.
UDT does not provide accurate information about how much or what dose of opioids or other drugs a patient took.
UDT results can be difficult to interpret and might sometimes be associated with practices that might harm patients (e.g., stigmatization, inappropriate termination from care).
Routine use of UDT with standardized policies at the practice or clinic level might destigmatize their use, and patterns of results are more important than a single test. It's important to understand metabolic pathways and technical issues related to assays used in your particular setting, and providers are highly encouraged to consult with the laboratory or local toxicologist for result interpretation.
Screening tests can vary in sensitivity and specificity. False positive and false negative results may occur. For instance:
Costs for tests and provider analysis time can be a burden for both patient and provider. In most situations, initial UDT can be performed with a relatively inexpensive immunoassay panel for commonly prescribed opioids and illicit drugs.
However, confirmatory tests ordered in response to an unexpected result on immunoassay screen may require referral to a higher-level laboratory, depending on local resources, adding time and expense to the UDT process.
Providers should not test for substances that would not be expected to affect patient management or for which implications for patient management are unclear.
When should UDT be performed?
Let's take a moment to review how you can discuss UDT results with a patient.
Use a statement such as: "I use urine drug testing with all patients who are prescribed controlled substances. The information can help me make sure that controlled substances are used in a way that is safe for patients."
Use statements such as:
"In general, the medication that I am prescribing should be in the urine. If it is not in the urine, there should be a clear reason for this that we should talk about before you give a urine sample. In addition, if other substances like illicit drugs are in the urine, then this is something that we should discuss during our visits."
"I never kick people out of care based on the results of a urine drug test. Instead, I use the results to help us have discussions about what is going on. In general, it's much better for you to tell me what the urine drug test will show than for me to be surprised. I can only help you if I understand what is happening."
Use a statement such as: "Will the urine drug test show anything other than the medication I am prescribing you? Will it show medications that other providers have prescribed? Will it show illicit drugs?"
Use a statement such as: "What will your urine drug test show today? Is there something you want to tell me about your urine drug test from your last visit?"
Discuss unexpected results with the local laboratory or toxicologist, as well as with the patient.
If unexpected results cannot be explained and if it is recommended by the test manufacturer, confirm results with a selective test such as via gas or liquid chromatography/mass spectrometry. Check with your local laboratory for options, which may include referral to a specialty laboratory.
Use unexpected results to improve patient safety. Do not dismiss patients from care based on a UDT result. Consider, as appropriate, a change in pain management strategy; tapering and discontinuing opioids; more frequent reevaluations; offering naloxone; or treatment for substance use disorder.
Doctor: "Hi Ms. Smith, how are you? As you know, we routinely use urine drug testing at our clinic to improve the safety of our patients. Before I order the test today, I want to discuss what I should expect. Will the urine show that you are taking the medication I am prescribing? Is it possible that there will be any unexpected results?"
Patient: "Hmmmm… It should show that I am taking my medicine. I don't think there will be anything unexpected."
Doctor: "Okay, thanks for letting me know. Let's proceed."
What are the most appropriate next steps before ordering the test? Select all that apply.
All of the answer choices are correct. You should have a plan in place to respond to unexpected results; request the appropriate assays for specific drugs, such as synthetic and semisynthetic opioids, if not already included on your practice's testing panel; ensure your patient and staff are familiar with your practice's UDT policy; and avoid testing for drugs if the results will not affect patient management.
Patients with a history of mental health conditions such as depression are at higher risk of opioid use disorder and overdose, as well as suicidal ideation. Also, psychological distress can interfere with improvement in pain and function in patients with chronic pain. Thus, it's important to screen for mental health conditions like depression and anxiety and ensure treatment for such conditions is optimized in patients taking opioids.
Use validated instruments, such as the Generalized Anxiety Disorder (GAD)-7 questionnaire or the Patient Health Questionnaire (PHQ)-9 or PHQ-4, when assessing for anxiety, depression, post-traumatic stress disorder (PTSD), and/or other mental health conditions.
Experts have noted that providers should use additional caution and increased monitoring to address the heightened risk for opioid use disorder among patients with mental health conditions (including depression, anxiety disorders, and PTSD), as well as increased risk for drug overdose among patients with depression.
Previous guidelines have noted that opioid therapy should not be initiated during acute mental health instability or uncontrolled suicidality, and that providers should consider behavioral health specialist consultation for any patient with a mental health condition especially with a history of suicide attempts.
Patients with anxiety disorders and other mental health conditions are more likely to receive benzodiazepines, which can exacerbate opioid-induced respiratory depression and increase risk for overdose.
Treatment for depression can improve pain symptoms as well as depression and might decrease overdose risk. For treatment of chronic pain in patients with depression, providers should strongly consider using tricyclic or SNRI antidepressants for analgesic as well as antidepressant effects if these medications are not otherwise contraindicated.
Recent analyses found that depressed patients were at higher risk for drug overdose than patients without depression, particularly at higher opioid dosages, although investigators were unable to distinguish unintentional overdose from suicide attempts.
Patient: Colsen, Julie
Medical History: Left hip osteoarthritis; Onset 2 years ago; Takes extended-release oxycodone 10mg twice per day; Yoga has helped to alleviate some of her pain
PDMP does not reveal any additional controlled substance prescriptions.
Doctor: "Hi Ms. Colsen, thanks for coming in today. How are you?"
Patient: "Well, I've been having a tough time standing up for long periods of time because my hip pain has been flaring up again and it's been affecting what I can do around the house, and I've been late for work several times because I can't get out the door quickly. I feel really depressed about it all."
Doctor: "I'm so sorry to hear that your pain is worse. What do you mean when you say you feel depressed about it all?"
Patient: "I know arthritis just won't go away on its own, and it makes me feel hopeless. I haven't been sleeping very well and I have lost my appetite."
Doctor: "Have you had any thoughts of hurting yourself or others?"
Patient: "No no, nothing like that. I just don't feel good about myself these days."
Doctor: "Okay, thanks for letting me know. Let's work together to come up with a plan."
Which of the following statements are true? Select all that apply.
The correct response is A, B, and C. Since Ms. Colsen has concurrent depression and opioid use, she is at a higher risk of opioid use disorder, overdose, and suicidality. Also, the doctor should use a validated instrument to diagnose and evaluate the severity of depression and consult with a behavioral health specialist to reduce the risk of harm.
Here's what we know...
Chronic pain management is a long-term collaborative process, and it is crucial that providers and patients agree on treatment goals and strategies.
Providers are encouraged to have open and honest discussions with patients to inform mutual decisions about whether to start or continue opioid therapy.
It's essential to communicate with patients before starting and periodically during opioid therapy regarding:
Providers and patients who set a plan in advance will clarify expectations regarding how opioids will be prescribed and monitored, as well as situations in which opioids will be discontinued or dosages tapered to improve safety. Opioids may be tapered and potentially discontinued if treatment goals are not met, opioids are no longer needed, or adverse events put the patient at risk.
Treatment goals should include improvement in both pain relief and function and therefore in quality of life.
Providers should use these goals in assessing benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy.
There are some clinical circumstances under which reductions in pain without improvement in physical function might be a more realistic goal, such as diseases typically associated with progressive functional impairment or catastrophic injuries such as spinal cord trauma.
Experts have noted that function can include emotional, social, and physical outcomes. Experts have also emphasized that mood and sleep have important interactions with pain and function.
Providers should discuss an opioid treatment plan with the patient. The provider should:
Providers may use validated instruments such as the three-item Pain average, interference with Enjoyment of life, and interference with General activity ("PEG") Assessment Scale, in order to track patient outcomes.
Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function.
Monitoring progress toward patient-centered functional goals (e.g., walking the dog or walking around the block, returning to part-time work, attending family sports or recreational activities) can also contribute to the assessment of functional improvement.
Given the increased risk of fatal overdose, concurrent prescribing of opioids and benzodiazepines should be avoided whenever possible. For patients taking both benzodiazepines and opioids, providers should:
Providers should also:
Patient: Sanders, Robert
No documentation of UDT is found. Medications are confirmed by the PDMP.
What should you discuss with your patient to increase the safety of his current medication regimen? Select all that apply.
That is incorrect. Actually, all answers are correct. To increase the safety of this patient's current medication regimen, it's important to:
Doctor: "Hi Robert, thanks for coming in today. I wanted to talk to you about your current medications. As you may know, you are on both a benzodiazepine—the alprazolam--and an opioid—the oxycodone tablets. There are some serious safety concerns about this. Continuing the current treatment is not safe and we need to discuss how we can make your treatment safer."
Patient: "If you think that is best. But I'm worried anything different won't work and that I will have more pain than I do now, which I really don't want..."
Select the statement the doctor should say next.
Choice A: I suggest that we slowly taper the oxycodone dose by about 10% per week. We can adjust that rate depending on how you are handling the taper. That way, we can minimize withdrawal symptoms.
Choice B: Let's talk to your psychiatrist about quickly tapering the alprazolam over the next week and starting something new for your anxiety. Also, I suggest that you increase the frequency of counseling and see your psychiatrist within a few weeks.
Choice A is correct. You should taper the opioid first if a medication taper is pursued, as it might be safer and more practical due to greater risks of benzodiazepine withdrawal relative to opioid withdrawal, and because tapering opioids can be associated with anxiety.
It's important to taper benzodiazepines gradually if discontinued because abrupt withdrawal can be associated with rebound anxiety, seizures, delirium tremens, or in rare cases, death.
Narration Text: Before starting opioid therapy for chronic pain, develop treatment goals with all patients; Consider known risks and benefits of opioid therapy eliciting patient views; Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dose escalation; Optimize other therapies and work with patients to taper opioids if benefits do not outweigh harms
Before starting opioid therapy for chronic pain, clinicians should develop treatment goals with all patients.
Consider known risks and benefits of opioid therapy, eliciting patient views.
Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or of dosage escalation.
Optimize other therapies and work with patients to taper opioids if benefits do not outweigh harms.
Doctor: "Robert, I think it's best to taper your oxycodone down and potentially stop it completely. We can try some other ways to manage your pain. In the end, this will be the safest option for you and will reduce your risk of overdose."
Patient: "I think this will be hard, but I am willing to give it a try if you think it is best."
Depending on the results of the UDT, PDMP, and medical evaluation, you will need to decide upon:
Note: Identification of an opioid use disorder can alter the expected benefits and risks of opioid therapy for pain, but patients with co-occurring pain and substance use disorder still require ongoing pain management that maximizes benefits relative to risks. If opioid use disorder is diagnosed, continue to use nonpharmacologic and nonopioid pharmacologic pain treatments as appropriate and consider consulting a pain specialist as needed to provide optimal pain management.
Evaluate risk factors for opioid-related harms before starting and periodically during continuation of opioid therapy.
Review the patient's history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.
Use urine drug tests 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.
Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
Offer or arrange evidence-based treatment for patients with opioid use disorder.
Supporting research can be found in the CDC Guideline for Prescribing Opioids for Chronic Pain.
You may now continue to the Training and Continuing Education Online System (TCEOnline) to receive continuing education credit for this training module.
Please register on TCEOnline, search for the course (WB2864), select the appropriate credit type, and complete the course evaluation and posttest in the Participant Services section.
Select Information for Providers at the URL below for clinical tools and other resources designed to help you apply these recommendations in your practice.