Opioid Crisis Update

William A. Hazel, Jr., MD
Secretary of Health and Human Resources

By William A. Hazel, Jr., MD
Secretary of Health and Human Resources

Dear Colleague,

There is an opioid overdose crisis in the United States. In 2014, there were 18,893 prescription drug overdose deaths and 10,574 heroin deaths, and there is broad agreement that a key ingredient to solving this problem is proper prescribing for pain management.

Accordingly, in March 2016 the Center for Disease Control released the Guideline for Prescribing Opioids for Chronic Pain. This guideline, which is summarized below, addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. The CDC has a number of related resources, such as a 2-page summary, a prescribing checklist and recommended non-opioid treatments, on their website. If you are a prescriber of opioids, I ask you to please review the full guideline, which contains background, documentation and rationale for the following recommendations:

Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Providers should only consider adding opioid therapy if expected benefits for both pain and function are anticipated to outweigh risks to the patient.
Before starting opioid therapy for chronic pain, providers should establish treatment goals with all patients, including realistic goals for pain and function. Providers should not initiate opioid therapy without consideration of how therapy will be discontinued if unsuccessful. Providers should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
Before starting and periodically during opioid therapy, providers should discuss with patients known risks and realistic benefits of opioid therapy and patient and provider responsibilities for managing therapy.
When starting opioid therapy for chronic pain, providers should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
When opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should implement additional precautions when increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should generally avoid increasing dosage to ≥90 MME/ day.
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, providers should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days usually will be sufficient for most non-traumatic pain not related to major surgery.
Providers should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation. Providers should evaluate benefits and harms of continued therapy with patients every three months or more frequently. If benefits do not outweigh harms of continued opioid therapy, providers should work with patients to reduce opioid dosage and to discontinue opioids.
Before starting, and periodically during, continuation of opioid therapy, providers should evaluate risk factors for opioid-related harms. Providers should incorporate into the management plan strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, or higher opioid dosages (≥50 MME), are present.
Providers should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving high opioid dosages or dangerous combinations that put him or her at high risk for overdose. Providers should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every three months.
When prescribing opioids for chronic pain, providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Providers should avoid prescribing opioid pain medication for patients receiving benzodiazepines whenever possible.
Providers should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.

These recommendations are aligned with initiatives that we are implementing as a result of the Governor’s Task Force on Prescription Drug and Heroin Abuse. Prescribers are now automatically registered with Virginia’s Prescription Monitoring Program, and starting July 1 will be required to check the PMP for most prescriptions lasting more than 14 days. The Board of Medicine is now allowed to require CME in opiate-related areas (beginning with 2018 renewals), and is convening a workgroup on buprenorphine.

Thank you for your attention to this critical issue. Together we will find ways to effectively manage our patients’ pain while also preventing addiction, misuse and overdose.

Sincerely,

William A. Hazel Jr., MD
Secretary of Health and Human Resources