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.

Methadone is widely used as a replacement for illicit opioid use such as heroin in medically-supported opioid substitution maintenance programmes. Two other drugs have been used to help reduce illicit opioid use, specifically buprenorphine and LAAM (levo-alpha-acetylmethadol). LAAM is not used in current clinical practice. Buprenorphine is currently used and can reduce illicit opioid use compared with placebo, although it is less effective than methadone. Buprenorphine is an opioid drug that is not as potent as heroin and methadone, although the effects of buprenorphine may last longer. Buprenorphine can be taken once every two days. The trials include different formulations of buprenorphine: sublingual solution, sublingual tablets, combined buprenorphine/naloxone sublingual tablet and an implant. Key results The review of trials found that buprenorphine at high doses (16 mg) can reduce illicit opioid use effectively compared with placebo, and buprenorphine at any dose studied retains people in treatment better than placebo. Buprenorphine appears to be less effective than methadone in retaining people in treatment, if prescribed in a flexible dose regimen or at a fixed and low dose (2 - 6 mg per day). Buprenorphine prescribed at fixed doses (above 7 mg per day) was not different from methadone prescribed at fixed doses (40 mg or more per day) in retaining people in treatment or in suppression of illicit opioid use.

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Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

A large fraction of heroin users now report that they formerly used prescription opioids nonmedically, a finding that has led to restrictions on opioid prescribing. Nevertheless, only a small fraction of prescription-opioid users move on to heroin use.

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Relationship between Nonmedical Prescription-Opioid Use and Heroin Use

Context No randomized trials have examined treatments for prescription opioid dependence, despite its increasing prevalence. Objective To evaluate the efficacy of brief and extended buprenorphine hydrochloride-naloxone hydrochloride treatment, with different counseling intensities, for patients dependent on prescription opioids. Design Multisite, randomized clinical trial using a 2-phase adaptive treatment research design. Brief treatment (phase 1) included 2-week buprenorphine-naloxone stabilization, 2-week taper, and 8-week postmedication follow-up. Patients with successful opioid use outcomes exited the study; unsuccessful patients entered phase 2: extended (12-week) buprenorphine-naloxone treatment, 4-week taper, and 8-week postmedication follow-up. Setting Ten US sites. Patients A total of 653 treatment-seeking outpatients dependent on prescription opioids. Interventions In both phases, patients were randomized to standard medical management (SMM) or SMM plus opioid dependence counseling; all received buprenorphine-naloxone. Main outcome measures Predefined "successful outcome" in each phase: composite measures indicating minimal or no opioid use based on urine test-confirmed self-reports. Results During phase 1, only 6.6% (43 of 653) of patients had successful outcomes, with no difference between SMM and SMM plus opioid dependence counseling. In contrast, 49.2% (177 of 360) attained successful outcomes in phase 2 during extended buprenorphine-naloxone treatment (week 12), with no difference between counseling conditions. Success rates 8 weeks after completing the buprenorphine-naloxone taper (phase 2, week 24) dropped to 8.6% (31 of 360), again with no counseling difference. In secondary analyses, successful phase 2 outcomes were more common while taking buprenorphine-naloxone than 8 weeks after taper (49.2% [177 of 360] vs 8.6% [31 of 360], P Conclusions Prescription opioid-dependent patients are most likely to reduce opioid use during buprenorphine-naloxone treatment; if tapered off buprenorphine-naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome is high, even in patients receiving counseling in addition to SMM.

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Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence A 2-Phase Randomized Controlled Trial

The effects of a substance use disorder (SUD) are felt by the whole family. The family context holds information about how SUDs develop, are maintained, and what can positively or negatively influence the treatment of the disorder. Family systems theory and attachment theory are theoretical models that provide a framework for understanding how SUDs affect the family. In addition, understanding the current developmental stage a family is in helps inform assessment of impairment and determination of appropriate interventions. SUDs negatively affect emotional and behavioral patterns from the inception of the family, resulting in poor outcomes for the children and adults with SUDs. Social workers can help address SUDs in multiple ways, which are summarized in this article.

The Impact of Substance Use Disorders on Families and Children: From Theory to Practice

In recent years there has been a dramatic increase in the abuse of and dependency on prescription opioid pain medications (also known as narcotics). Viewed as safer than street drugs like heroin, prescription pain pill misuse is on the increase in all age ranges. Frequently abused prescription pain medications include hydrocodone (Lorcet, Lortab, Vicodin), oxycodone (OxyContin, Percocet, Percodan), codeine (Tylenol 2s, 3s, and 4s), fentanyl (Duragesic), and morphine (MS Contin). These drugs are commonly prescribed for acute pain (for example, tooth, post-injury, or surgery pain) or chronic pain (for example, back pain or pain associated with malignancy). Methadone, which is used both for the treatment of opioid dependence and for pain, is rising as a primary drug of abuse as well (Maxwell, 2006). Statistics over the past five years have shown that the misuse of prescription pain medications by students in grades 8 through 12 continues to rise, whereas use of illegal drugs, tobacco, alcohol, and steroids has decreased. Data from admissions to treatment facilities show that heroin as a primary drug of choice decreased from 2000 to 2005; during that same time period, admissions for other opioids increased (Center for Substance Abuse Research, 2007). According to the National Survey on Drug Use and Health (NSDUH) report (NSDUH, 2006), nonmedical use of prescription pain medications has increased among young adults ages 18 to 25. More people initiated use of prescription pain relievers in 2004 than began using marijuana or cocaine. Often these drugs are relatively easy to obtain, are viewed as safer than illegal drugs, and are less shameful to use. Although prescription pain pills are from the same class of drugs as heroin, the difficulty of diagnosis of abuse and dependence on them is increased because of their legitimate use and surrounding misconceptions. National Center of Health Statistics (Maxwell, 2006) data indicated that narcotic analgesics such as hydrocodone, oxycodone, and methadone were more likely to be the cause of death in accidental overdoses than either heroin or cocaine. The 213 percent increase in methadone accidental poisoning deaths between 1999 and 2003 was associated with the use of methadone as a pain medication rather than in opioid treatment programs (Maxwell, 2006). Such alarming statistics about the increase in the prevalence of prescription pain medication misuse with the corresponding damage to individuals and to society calls for study and better services. Individuals who abuse pain medication present a unique population in their sociodemographic characteristics and drug use patterns. More than half of the new users of prescription pain relievers are female, the average age of first nonmedical use of pain relievers was 25, and almost 90 percent of new users are white (NSDUH, 2006). This increase in the abuse of opioids by this group raises the need to target this population for treatment and to examine the effectiveness of existing treatment modalities. BUPRENORPHINE/NALOXONE AS A NEW PHARMACOLOGICAL TREATMENT Buprenorphine/naloxone, is an evidence-based pharmacological treatment that offers a new and different option for treatment of opioid dependence. This medication blocks the effects of other opioids and is difficult to abuse. It has been demonstrated to be effective with heroin dependence (Fiellin et al., 2002; Ling et al., 1998; Prescrire Editorial Staff, 2006), and studies are now being conducted by the National Institute on Drug Abuse (NIDA) to demonstrate its effectiveness with those dependent on prescription pain medication (see NIDA Clinical Trials Network at http://www.nida.nih.gov/ CTN/protocol/0030.html). Beginning in October 2002, physicians who take a sanctioned course can prescribe buprenorphine/naloxone as a sublingual tablet for opioid addiction from a private office rather than exclusively through specialized drug treatment centers. …

Marilyn Byrne

Papers

Adjunctive Counseling During Brief and Extended Buprenorphine-Naloxone Treatment for Prescription Opioid Dependence A 2-Phase Randomized Controlled Trial

The Impact of Substance Use Disorders on Families and Children: From Theory to Practice

The Changing Face of Opioid Addiction: Prescription Pain Pill Dependence and Treatment

Socioenvironmental aspects of substance use disorders.