How Do I Know If I Should Prescribe Opioids?
Author: Christine Zink, MD
Opioid misuse and overdose is an ongoing epidemic and public health emergency in the United States. Almost 850,000 people have died from a drug overdose since 1999.1 Over 70,000 people died in 2019, and 70% of them involved an opioid.1 This article will detail the rise of the opioid epidemic, highlight how educational and governmental institutions have responded to the crisis through education campaigns directed toward clinicians, and describe the Centers for Disease Control’s (CDC) guidelines for prescribing opioids for chronic pain in the United States. Here are the key takeaways:
- With reassurance from pharmaceutical companies that their products were not addictive, clinicians increased opioid prescribing throughout the 1990s
- Over 10 million people misused prescription opioids in 2019
- Most practicing physicians do not have formal education in prescribing opioids
- Prescription Drug Monitoring Programs seem to reduce opioid prescribing and overdose deaths
- Most, but not all, states have opioid prescribing or pain management continuing medical education requirements for licensure
- Over 50 million people live with chronic pain in the United States
- To help combat the struggles in understanding the complex nature of chronic pain and appropriate prescribing practices, the Centers for Disease Control developed guidelines for prescribing opioids for chronic pain, and the American Academy of Family Physicians recently reaffirmed the guidelines
- Free opioid continuing medical education is online
Prescription opioids treat acute and chronic pain. Regular prescribing of opioid pain medicine took off in the 1990s when pharmaceutical companies reassured healthcare providers that their products were not addictive.2 It turns out that the medications were highly addictive, which led to the rising use of higher doses of prescription opioids and greater numbers of people using heroin when prescription pills were not available. Physician over-prescribing has been a significant contributor to the opioid epidemic.3 Over 10 million people misused prescription opioids in 2019.2 Physicians are usually well-intentioned when it comes to prescribing opioids, but education on prescribing practices has only been introduced recently and varies widely across medical institutions.3
In response to the opioid epidemic, US medical schools have been incorporating pain management and substance use disorder classes into their education programs.3 In 2018, the Association of American Medical Colleges found that 87% of schools covered pain management education.3 However, teaching methods and educational content vary widely.3 Additionally, these programs were recently implemented into medical education, meaning that most practicing healthcare providers lack formal training in pertinent opioid prescribing practices.4
The rising problem of opioid addiction became apparent in the early 2000s. It was not until then that drug manufacturers and states started implementing education programs on appropriate opioid prescribing. Through the Opioid Risk Evaluation and Mitigation Strategy, drug manufacturers were required to develop educational material and training for clinicians on how to prescribe opioids.4,5 States have been slowly implementing required continuing medical education (CME) for clinician licensure, and the government has instituted prescription drug monitoring programs under the National All Schedules Prescription Electronic Reporting Act, the law signed in 2005 that provides for the establishment of controlled substances monitoring programs in each state. These steps seem to have reduced the number of opioid prescriptions by about 8% and opioid overdose deaths by about 12%.6 Each state’s medical licensing board has its own set of CME requirements for each type of medical professional. Several states implemented these education requirements over the last five years.7 Still, Hawaii, Idaho, Kansas, Minnesota, Missouri, Montana, North Dakota, South Dakota, and Wyoming do not have specific opioid or pain management CME requirements.7 Colorado only has requirements for physician assistants, not physicians.7 However, it is essential for all clinicians to obtain opioid prescribing education and follow specific standards to combat the opioid epidemic.
Approximately 50 million adults have chronic pain, and it is one of the most common reasons people seek medical care.8 Living with chronic pain decreases a person’s quality of life.8 However, clinicians write enough opioid prescriptions so that every adult in the United States has a bottle of pills.9 Clinicians walk a challenging line between overprescribing opioid medication and effectively managing a patient’s pain. To help combat the struggles in understanding the complex nature of chronic pain and appropriate prescribing practices, the CDC developed guidelines for prescribing opioids for chronic pain. These guidelines have been reaffirmed by several organizations, including the American Academy of Family Physicians.10
The CDC guidelines provide primary care clinicians guidance on prescribing opioids for people with chronic pain who do not have cancer, require palliative care, or are at the end of life. These guidelines address9:
- When to initiate or continue opioids for chronic pain
- Opioid selection, dosage, duration, follow up, and discontinuation
- How to assess risk and address the harms of opioid use
These guidelines also aim to improve communication between clinicians and patients about the benefits and risks of opioid therapy, improve the safety and effectiveness of pain treatments, and reduce the risks associated with long-term opioid treatment. The 12 recommendations are summarized below9:
- Nonpharmacological therapy and nonopioid pharmacological therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function outweigh the risks to the patient.
- Clinicians should establish realistic pain and function treatment goals with each patient before initiating opioid therapy.
- Clinicians should discuss the risks and benefits of patient treatment at initiation and periodically during the management course.
- Clinicians should prescribe immediate-release opioids instead of extended-release options.
- Clinicians should prescribe the lowest effective dose of opioid therapy, and they should very carefully reassess the benefits and risks when considering a dosage increase. Additionally, clinicians should avoid increasing the dosage by ≥90 morphine milligram equivalents per day.
- When prescribing opioids for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and prescribe a quantity needed for the expected duration of pain. Three days or less is usually sufficient, and more than seven days is rarely needed.
- When prescribing opioids for chronic pain, clinicians should reevaluate the benefits and harms within four weeks of starting treatment. After that, clinicians should continue to review the management program every three months.
- Clinicians should consider offering naloxone if there is an increased risk for opioid overdose, particularly if the patient has a history of a substance use disorder, is using higher opioid dosages, or is concurrently taking benzodiazepines.
- Clinicians need to regularly monitor the patient’s history of controlled substance prescriptions using a state prescription drug monitoring program.
- When prescribing opioids for chronic pain, clinicians should consider using urine drug testing before starting therapy and at least annually to assess for other controlled substances.
- Clinicians should avoid prescribing opioid pain medication and benzodiazepines at the same time.
- Clinicians should offer evidence-based treatment for patients with opioid use disorder. This usually means medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies.
Several organizations offer free opioid CME, and opioid prescribing education is essential to every primary care clinician’s practice. You can take courses to fulfill your state’s specific CME/CE requirements at Pri-Med.com. For those who reside in a state without specific opioid CME requirements, opioid education often meets other state CME requirements for categories such as pain management, ethical and legal issues, and controlled substances. Take free opioid CME/CE courses at Pri-Med, and make a difference in the nation’s opioid epidemic.
2. US Department of Health and Human Services. What is the opioid epidemic?. Updated February 19, 2021. Accessed September 28, 2021.
3. Singh R, Pushkin GW. How should medical education better prepare physicians for opioid prescribing? AMA J Ethics. 2019;21(8):E636–641.
4. Partnership to End Addiction. Calls grow for mandatory education for physician opioid prescribing. Published October 2011. Accessed September 28, 2021.
5. American Academy of Family Physicians. Pain management and opioid abuse: a public health concern. Published July 2012. Accessed September 28, 2021. https://www.aafp.org/dam/AAFP/documents/patient_care/pain_management/opioid-abuse-position-paper.pdf
6. Jones MR, Viswanath O, Peck J, Kaye AD, et al. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther. 2018 Jun; 7(1):13-21. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5993682/#__ffn_sectitle
7. New England Journal of Medicine Knowledge+. State requirements for pain management CME. Updated April 9, 2020. Accessed September 28, 2021. https://knowledgeplus.nejm.org/cme-moc/pain-management-and-opioids-cme/state-requirements-for-pain-management-cme/
8. Centers for Disease Control. Managing chronic pain. Updated December 18, 2019. Accessed September 28, 2021. https://www.cdc.gov/learnmorefeelbetter/programs/chronic-pain.htm
9. Centers for Disease Control. CDC guideline for prescribing opioids for chronic pain- United States, 2016. Recommendations and Reports. 2016 Mar; 65(1);1-49. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
10. American Academy of Family Physicians. Clinical practice guideline: opioid prescribing for chronic pain. Updated July 2021. Accessed September 28, 2021. https://www.aafp.org/family-physician/patient-care/clinical-recommendations/all-clinical-recommendations/opioid-prescribing.html