Importance Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. Objective To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Process The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. Evidence Synthesis Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. Recommendations There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. Conclusions and Relevance The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.

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CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

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CDC guideline for prescribing opioids for chronic pain

This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.

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CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016.

This paper documents a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. We comment on potential economic causes and consequences of this deterioration.

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Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century.

Non-specific low back pain

Prescriptions of opioid medications for chronic pain have increased dramatically, as have opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness This review found s

http://unmhospitalist.pbworks.com/w/file/fetch/93549860/0000605-201502170-00006.pdf

The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Treatments for Schizophrenia in Adults: A Systematic Review

: The objective of this report is to describe the methods used in and lessons learned from a research study that evaluated prescriptions for medication errors prior to the implementation of an ambulatory computerized prescriber order entry (ACPOE) system in a community-based, integrated health system. Several aspects of the study are described: practice setting, research team, project scope and study design, data elements, database creation, data sources, study methods, evaluation methods, refinements, and current project status. Lessons learned are summarized. Focused attention to these aspects, a priori, resulted in the collection of data that have been used to characterize the epidemiology of medication errors at baseline. By repeating these same methods post-ACPOE implementation, the impact of the ACPOE system on medication errors will be determined. The methods used to measure the baseline rate of medication errors provided useful results and proved practical in a practitioner-based organization. This design can be replicated in similar organizations desiring to evaluate the impact of an ACPOE system on medication errors.

/pdf/preparing-for-ambulatory-computerized-prescriber-order-entry-3ro4yum2sx.pdf

Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors

Objectives: To (1) describe the role of clinical pharmacists in providing population-based pharmaceutical care as employees of a physician group practice, (2) describe the strategies used by pharmacists to optimize medication use, (3) quantify improvements in care, and (4) illustrate the calculations used to quantify cost savings. Setting: Community-based, multispecialty, physician group practice located in the north Puget Sound area between 2003 and 2007. Practice description: Using four cornerstones (evidence-based medicine, therapeutic interchange, academic detailing, and a local pharmacy and therapeutics committee), the pharmacists provided population-based pharmaceutical care, leading generic switches, target drug programs, and prescription to over-the-counter medication switches. They also led disease management programs, managed drug recalls, implemented electronic health records, negotiated budgets with health plans, and led patient assistance programs and prior authorization programs to improve patient satisfaction. Practice innovation: Implementing these strategies from the vantage point of a physician group presents a seldom-realized employment opportunity for pharmacists. Main outcome measures: The impact of these strategies is measured by process, use, and clinical outcomes metrics. These, in turn, are linked to incentive payments in the pay-for-performance environment or to a lowered per member, per month cost in the capitated environment. Results: In 2006–2007, 71% of our hypertensive patients received generic agents compared with a network average for receiving generic agents of 43%, while the proportion of patients with controlled blood pressure increased from 45% to 60%. We saved $450,000 in inpatient costs for deep venous thrombosis.

https://www.japha.org/article/S1544-3191(15)30959-6/pdf

Emily B Devine

Papers

The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop

Treatments for Schizophrenia in Adults: A Systematic Review

Preparing for Ambulatory Computerized Prescriber Order Entry by Evaluating Preimplementation Medication Errors

Strategies to optimize medication use in the physician group practice: The role of the clinical

Table 2, NCC MERP Definition of a medication error and Risk Assessment Index