• Patients older than 65. Because of decreasing renal function, this population is at risk for the accumulation of opioids and may be unable to tolerate nonopioid pharmacologic therapy such as NSAIDs as a result of comorbidities. When opioids are necessary, the recommendations indicate a need for fall risk assessment, monitoring for cognitive impairment, and an appropriate bowel regimen.
• Patients with mental health conditions. These patients pose a high risk for overdose both because of polypharmacy, specifically benzodiazepine use, and mental instability. Make sure patients are being optimally treated for their mental health disorders, and when possible consider the use of tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors for additional pain relief.
• Patients with substance use disorders. Those who use illicit substances contribute to a significant proportion of deaths related to opioid use. However, the previously recommended risk assessment tools were found to be inaccurate and should not provide clinicians with a sense of security when prescribing to this patient population. In addition, consulting a substance use disorder specialist and/or pain specialist may be best for this population.
The bottom line
Opioid use has been increasing steadily in the United States with a proportional increase in opioid overdoses. The CDC guidelines present a strategy to prescribing opioids that emphasizes caution, careful decision making, and monitoring when prescribing opioids in order to best control pain while mitigating the risks of opioid use disorder and overdose.
Reference
CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-50.
Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Carcia is currently a third-year resident and chief resident in the family medicine program at Abington Memorial Hospital.