When Your Prescribe: Start Low and Go Slow
Opioids can provide short-term benefits for moderate to severe pain. Scientific evidence is lacking for the benefits to treat chronic pain (for adults 18+ with chronic pain > 3 months excluding active cancer, palliative, or end-of-life care).·
Before Prescribing, Assess Pain & Function
- Use a validated pain scale. Example: PEG scale where the score = average 3 individual question scores percent improvement from baseline is clinically meaningful).
- Q1: What number from 0 – 10 best describes your PAIN in the past week? (0 = “no pain”, 10 = “worst you can imagine”)
- Q2: What number from 0 – 10 describes how, during the past week, pain has interfered with your ENJOYMENT OF LIFE? (0 = “not at all”, 10 =“complete interference”)
- Q3: What number from 0 – 10 describes how, during the past week, pain has interfered with your GENERAL ACTIVITY? (0 = “not at all”, 10 = “complete interference”)
- Consider if Non-Opioid Therapies are Appropriate
- Such as: NSAIDs, TCAs, SNRIs, anti-convulsants, exercise or physical therapy, cognitive behavioral therapy.
- Talk to Patients About Treatment Pan
- Set realistic goals for pain and function based on diagnosis.
- Discuss benefits, side effects, and risks (e.g., addiction, overdose).
- Set criteria for stopping or continuing opioid. Set criteria for regular progress assessment.
- Check patient understanding about treatment plan.
Evaluate Risk of Harm or Misuse. Check:
- Known risk factors: illegal drug use — prescription drug use for nonmedical reasons; history of substance use disorder or overdose; mental health conditions; sleep-disordered breathing.
- Prescription drug monitoring program data (if available) for opioids or benzodiazepines from other sources. Urine drug screen to confirm presence of prescribed substances and for undisclosed prescription drug or illicit substance use.
- Medication interactions. AVOID CONCURRENT OPIOID AND BENZODIAZEPINE USE WHENEVER POSSIBLE.
When Your Prescribe: Start Low and Go Slow
- Start with immediate-release (IR) opioids at the lowest dose for the shortest therapeutic duration.
IR opioids are recommended over ER/LA products when starting opioids.
- Avoid ≥ 90 MME/day; consider specialist to support management of higher doses.
If prescribing ≥ 50 MME/day, increase follow-up frequency; consider offering naloxone for overdose risk.
- For acute pain: prescribe < 3 day supply; more than 7 days will rarely be required.
- Counsel patients about safe storage and disposal of unused opioids.
See below for MME comparisons. For MME conversion factors and calculator.
50 MORPHINE MILLLIGRAM EQUIVALENTS (MME)/DAY:
- 50 mg of hydrocodone (10 tablets of hydrocodone/acetaminophen 5/300)
- 33 mg of oxycodone (~2 tablets of oxycodone sustained-release 15mg)
90 MORPHINE MILLLIGRAM EQUIVALENTS (MME)/DAY:
- 90 mg of hydrocodone (18 tablets of hydrocodone/acetaminophen 5/300)
- 60 mg of oxycodone (4 tablets of oxycodone sustained-release 15mg)
After Initiation of Opioid Therapy – Assess, Tailor & Taper
- Reassess benefits/risks within 1-4 weeks after initial assessment.
- Assess pain and function, compare results to baseline. Schedule reassessment at regular intervals (≤ 3 months).
- Continue opioids only after confirming clinically meaningful improvements in pain and function without significant risks or harm.
- If over-sedation or overdose risk, then taper. Example taper plan: 10 percent decrease in original dose per week or month. Consider psychosocial support.
- Tailor taper rates individually to patients and monitor for withdrawal symptoms.
Treating Opioid Addiction
- Screen for opioid use disorder (e.g., difficulty controlling use; see DSM-5 criteria). If yes, treat with medication-assisted treatment (MAT). MAT combines behavioral therapy with medications like methadone, buprenorphine, and naltrexone.
- Learn about medication-assisted treatment (MAT) and apply to be a MAT provider at www.samhsa.gov/medication-assisted-treatment.
- Consider offering naloxone if high risk for overdose: history of overdose or substance use disorder, higher opioid dosage (≥ 50 MME/day), concurrent benzodiazepine use.
CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN:
SAMHSA POCKET GUIDE FOR MEDICATION-ASSISTED TREATMENT (MAT):
ENROLL IN MEDICARE: go.cms.gov/pecos Most prescribers will be required to enroll or validly opt out of Medicare for their prescriptions for Medicare patients to be covered. Delay may prevent patient access to medications.