CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016 | Guidelines | JAMA | JAMA Network
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    1 Comment for this article
    EXPAND ALL
    MME conversion
    Jeffrey T Junig MD PhD | Fond du Lac Psychiatry
    Setting a maximum morphine equivalency is somewhat arbitrary. Clinicians understand tolerance, and hopefull will make appropriate clinical decisions based on the balance of risks, with your chosen MME as a factor in those decisions.

    I have two concerns. First, morphine bioavailability varies 3-fold from oral to parenteral dosing. I assume, since we are discussing chronic pain, that you are referring to 50 mg of ORAL morphine? That distinction should be clarified.

    Second, insurers and regulators will not understand that in clinical medicine, amounts proposed as 'guidelines' may not be appropriate for all patients. Today I received
    8 more letters from an insurance company containing forms for me to complete, because they believe that 16 mg of sublingual buprenorphine exceeds your MME. I'll be writing to them next to try to explain the non-linear dose/response curve for partial agonists like buprenorphine. I fear that your 50 mg MME will be a cut-off for insurance coverage at some point, given current trends in medicine. When that happens, do you have a phone number I can have them call?
    CONFLICT OF INTEREST: None Reported
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    Special Communication
    April 19, 2016

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

    Author Affiliations
    • 1Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
    JAMA. 2016;315(15):1624-1645. doi:10.1001/jama.2016.1464
    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 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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