In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for safe opioid prescribing for chronic pain. Based on an updated evidence review, the CDC has revised the guidelines and released the Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022, include recommendations for outpatient acute, subacute, and chronic opioid use. The twelve recommendations fall into four broad categories: determining whether or not to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use. The CDC will update and develop tools and resources to support dissemination of these guidelines. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care, or for patients in the emergency department or admitted to the hospital.

Adherence to prescribing guidelines for appropriate opioid dosing and duration can decrease the risk of opioid-related harm. In this retrospective analysis of nationally representative outpatient claims data, researchers found that over a 4-6 month period, 28% of Medicaid and 35% of privately-insured patients had at least one pain-related visit and 35% of all enrollees had one or more opioid prescriptions. Opioid prescribing rates varied depending on the specific medical indication and the patient’s opioid prescribing history. The researchers found that prescribing rates of many pain medical indications were not always aligned with current guidelines. For example, patients with chronic non-cancer pain conditions undergoing long-term opioid therapy were commonly prescribed daily doses above the threshold for which adverse events, such as overdose, are increased.

Improving opioid prescribing is a complex challenge that requires multipronged approaches to achieve safe patient pain management. This commentary offers insights to help organizations effectively implement the Centers for Disease Control and Prevention guideline and notes how misapplication of recommendations have resulted in unintended consequences such as patient harm.

Opioid overdose deaths remain a threat to patient safety. Information about how overdose deaths are nationally distributed is critical to inform prevention efforts. This robust analysis examined all drug overdose deaths in the United States over a 38-year period. Drug overdoses began increasing exponentially long before the opioid prescribing boom in the mid-1990s and continue to rise in this way. Demographically distinct subepidemics of prescription opioid, synthetic opioid, and stimulant use all contribute to drug overdose deaths as a whole. The authors speculate about what factors other than opioid prescribing might drive escalating substance use-related deaths. An Annual Perspective and a PSNet perspective provide further insights into how safety efforts can reduce opioid-related harm.

This analysis of retail prescription data revealed that opioid prescribing has declined from a peak in 2010, but it remains higher than in 1999. Increased rates of opioid prescribing occurred in areas that are not urban, have a greater proportion of white populations, and higher unemployment and Medicaid enrollment. These results are consistent with prior studies about the opioid epidemic.

Opioid-related harm, including overdose deaths, has reached epidemic proportions. This study used a difference-in-differences analysis to examine whether a policy approach could reduce harm from opioid misuse. Investigators compared states with and without mandated provider review of drug monitoring data. In states with mandated review, opioid prescribers must check whether patients are receiving opioids from multiple prescribers and identify the total prescribed opioid dose. States with mandated review policies had fewer opioid overdose deaths and lower amounts of opioids prescribed than states without mandated prescriber review. These results are consistent with a prior study that established the benefit of prescription drug monitoring programs. The authors assert that despite the effectiveness of this policy, more interventions are needed to enhance opioid safety, as suggested in a recent study. A previous WebM&M commentary described opioid-related harm.

… dispensing naloxone to prevent overdoses. A previous WebM&M commentary describes an adverse event related to opioids. …

In this AHRQ-funded study, investigators conducted focus groups with patients to explore health care quality and safety issues. The authors conclude that patients can provide important insight for systems improvement and error reduction.