In this episode, I’ll discuss what an inpatient pharmacist needs to know about the outpatient CDC opioid guidelines.
The CDC has updated its Clinical Practice Guideline for Prescribing Opioids for Pain and published it in the first Morbidity and Mortality Weekly Report of November 2022.
The guideline specifically states that:
The recommendations do not apply to care provided to patients who are hospitalized or in an emergency department or other observational setting from which they might be admitted to inpatient care.
However this does not mean hospital-based clinicians can ignore the guideline recommendations, as the very next sentence states:
These recommendations do apply to prescribing for pain management for patients when they are discharged from hospitals, emergency departments, or other facilities.
If you have done any inpatient pain management as a pharmacist, you know that physicians and patients expect that before a patient is discharged, their home regimen will be working satisfactorily while the patient is still in the hospital. This means that you can’t simply use one style of opioid dosing while the patient is in the hospital and instantly change to something else when the patient goes home.
While the guideline covers many recommendations including non-opioid and non-pharmacologic recommendations, some of the most relevant ones for a hospital pharmacist helping with pain management and getting a patient on a stable regimen to be discharged revolve around selecting opioids and determining opioid dosages.
Recommendation 3 states:
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
This recommendation covers not using ER/LA opioids for acute pain and not prescribing these opioids for intermittent or as-needed use. In addition this recommendation covers reducing total daily dose to account for incomplete cross-tolerance when switching from an immediate acting opioid to a long-acting version of a different opioid.
Recommendation 4 states:
When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.
In an editorial published in NEJM the authors of the guidelines explain they left out of the recommendation text specific doses of opioids because they did not want thresholds for opioid doses to be misapplied. However they do provide examples in the explanatory text below the recommendation:
The lowest starting dose for opioid-naïve patients is often equivalent to a single dose of approximately 5–10 MME or a daily dosage of 20–30 MME/day.
Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day but are exposed to progressive increases in risk as dosage increases. Therefore, before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks…Additional dosage increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits for pain and function relative to risks to patients as dosage increases further.
Recommendation 11 states:
Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants
The guideline author specifically list muscle relaxants, nonbenzodiazepine sedative-hypnotics, and potentially sedating anticonvulsant medications such as gabapentin and pregabalin as the main CNS depressants to be concerned about prescribing with opioids. In addition they highlight that the risks of concurrent opioid and benzo use are probably the highest when there is unpredictable use of either medication, use of high doses, or use with alcohol when compared to “long-term, stable use of lower-dosage opioids and lower-dosage benzodiazepines without other substances [like alcohol].”
Throughout the guideline text the authors have gone to great lengths to emphasize that the guidelines should not be misapplied or that policies should not be derived from it that are beyond its intended use for outpatient prescribing of opioids in adult outpatients who do not have sickle cell disease, cancer-related pain, or the need for palliative care and end-of-life care. While the guidelines are responsibly written I think it is still highly likely that they may be taken out of context and misapplied. Hospital pharmacists who are aware of the intended application of the guidelines can be ready to prevent or correct any misapplication.
Consider sharing this episode with colleagues so that more people will be aware of the intended application of these guidelines.
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