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

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      , MD, MPH, , PhD, , MD
      JAMA

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          Abstract

          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 affects.

          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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          Author and article information

          Journal
          7501160
          5346
          JAMA
          JAMA
          JAMA
          0098-7484
          1538-3598
          19 February 2019
          19 April 2016
          26 February 2019
          : 315
          : 15
          : 1624-1645
          Affiliations
          Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
          Author notes

          Author Contributions: Drs Dowell and Chou had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

          Study concept and design: Dowell, Haegerich.

          Acquisition, analysis, or interpretation of data: Dowell, Haegerich, Chou.

          Drafting of the manuscript: Dowell, Haegerich, Chou.

          Critical revision of the manuscript for important intellectual content: Dowell, Haegerich, Chou.

          Statistical analysis: Chou.

          Administrative, technical, or material support: Haegerich.

          Study supervision: Dowell, Haegerich.

          Additional Contributions: We acknowledge Jeanmarie Perrone, MD, Matthew Bair, MD, and David Tauben, MD, for conducting initial peer reviews of the guideline for the CDC prior to journal submission; peer reviewers were not compensated for their contributions. We acknowledge Don Teater, MD, for facilitating the Core Expert Group. We acknowledge the work that the medical writers, editors, and reviewers from Ariande Labs provided to produce the checklist for prescribing opioids for chronic pain.

          Corresponding Author: Deborah Dowell, MD, MPH, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, ( ddowell@ 123456cdc.gov ).
          Article
          PMC6390846 PMC6390846 6390846 hhspa1008876
          10.1001/jama.2016.1464
          6390846
          26977696
          b67dbbfb-34ee-413c-afb4-2def51b71ed8
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