1. Navigating the Opioid Dilemma:
An Overview of Recommendations Guiding Today’s Pain Management
ZOH-US /2016

2. [Presenter photo here]
[HCP Presenter name here]
[Bio here]
This program is sponsored by Pernix Therapeutics. The speaker for this program has been selected by Pernix and is presenting on behalf of Pernix.

3. AFTER COMPLETING THIS PROGRAM, YOU SHOULD BE ABLE TO:
TODAY’S CALL TO ACTION
AFTER COMPLETING THIS PROGRAM, YOU SHOULD BE ABLE TO:
UNDERSTAND
the key features of the National Pain Strategy and CDC Guideline for Prescribing Opioids for Chronic Pain
Deliver
continued adequate patient care while practicing medicine in a new post-CDC guideline environment
DEMONSTRATE
appropriate usage of opioids in pain management through proper assessment of patient characteristics

4. PROGRAM OVERVIEW
An Overview: Chronic Pain and the Opioid Epidemic 1
National Pain Strategy and
CDC Guideline for Prescribing Opioids for Chronic Pain 2
Navigating the Evolving Landscape Created by the CDC Guideline 3
Identifying Appropriate Use for Extended Release Opioids 4 4

5. Are you aware of the national pain strategy?
Are you aware of the cdc guideline for prescribing opioids for chronic pain management?

6. An Overview:
Chronic Pain and the Opioid Epidemic

7. THE BURDEN OF PAIN: CHRONIC PAIN IS WIDESPREAD IN THE UNITED STATES
Chronic pain afflicts more Americans than diabetes, heart disease, and cancer combined1-4
National Academies Press, pp. 1A
Roger, pp. e203A
American Diabetes Association, pp. 1A
American Cancer Society, pp. 2A
Low back pain is the most prevalent type of chronic pain5
Back pain is the leading cause of disability in Americans under 45 years old
AAPM
pp. 2C
AAPM
pp. 2B
CHRONIC PAIN IMPOSES A TREMENDOUS FINANCIAL AND SOCIAL BURDEN5
The total annual incremental cost of health care due to pain ranges from $560 billion to $635 billion in the United States*
50%-75% of hospitalized patients die in moderate to severe pain
~20% of American adults (42 million people) report that pain or physical discomfort disrupts their sleep a few nights a week or more
*2010 dollars; estimate combines the medical costs of pain care and the economic costs related to disability days and lost wages and productivity. 1. National Academies Press, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Accessed November 30, American Diabetes Association, Statistics About Diabetes. Accessed November 30, Roger VL, et al. Circulation. 2011;123(4):e18-e American Cancer Society, Cancer Prevalence: How Many People Have Cancer? Accessed November 30, American Academy of Pain Medicine, Facts and Figures on Pain. Accessed July 27, 2016.

8. HOW DOES CHRONIC PAIN ADVERSELY IMPACT QUALITY OF LIFE?
Chronic pain can have devastating effects on public health, leaving Millions of Americans in Search of Effective Treatment
AAPM
pp. 3A
AAPM
pp. 3A
51% of individuals with chronic pain feel that they have little or no control over their condition
60% report breakthrough pain at least once daily, severely impacting quality of life and well-being
HOW DOES CHRONIC PAIN ADVERSELY IMPACT QUALITY OF LIFE?
AAPM
pp. 3B
American Academy of Pain Medicine, Facts and Figures on Pain. Accessed July 27, 2016.

9. OPIOID PRESCRIPTIONS DISPENSED BY US RETAIL PHARMACIES, 1991-20131
OPIOIDS AND PAIN: A COMPLEX DILEMMA OPIOID MISUSE, ABUSE, AND OVERDOSE REPRESENT AN EPIDEMIC THAT HAS LED TO DEBILITATING SOCIETAL PROBLEMS
Total
Hydrocodone
Oxycodone
OPIOID PRESCRIPTIONS DISPENSED BY US RETAIL PHARMACIES,
INCREASE IN PRESCRIPTION OPIOID
OVERDOSE-RELATED DEATHS, 16
NIDA
pp. 3A
Rudd
pp. 1379A
All drug overdose deaths
Drug overdose deaths involving opioids 14 12 10
Deaths per 100,000 population 8 6 4 2
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
1. National Institute on Drug Abuse, America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. addiction-to-opioids-heroin-prescription-drug-abuse. Accessed July 27, Rudd RA, Aleshire N, Zibbell JE, Gladden RM. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):

10. CURRENT PERSPECTIVES ON OPIOID USE IN CHRONIC PAIN: THE OPIOID EPIDEMIC HAS CAPTURED THE ATTENTION OF THE MEDIA AND THE PUBLIC

11. Are the current perspectives on opioids consistent with what you see in your community?
How DO YOU CONTINUE to provide ADEQUATE care TO patients who suffer from chronic pain?

12. GOVERNMENT RECOMMENDATIONS
CHRONIC PAIN AND OPIOID USE REPRESENT A COMPLEX DILEMMA FOR PROVIDERS AND POLICY-MAKERS ALIKE
UNMET NEEDS
Addressing the needs of patients with chronic pain
Managing the quality of patient care
Maximizing patient safety
Clinician education and guidance on opioid prescribing
GOVERNMENT RECOMMENDATIONS
National Pain Strategy (NPS)
CDC Guideline for Prescribing Opioids for Chronic Pain

13. An Overview: The National Pain Strategy (NPS)

14. What Is the National Pain Strategy?
DHHS
pp. 3A
INITIAL GOAL:
To undertake a study and make recommendations “to increase the recognition of pain as a significant public health problem in the United States”
FINAL INTENT:
To reduce the burden of pain for individuals, their families, and society as a whole
DHHS
pp. 3A
VISION:
To decrease the prevalence of pain across its continuum from acute to high-impact chronic pain and its associated morbidity and disability across the lifespan
2010
2011
2015
2016
DHHS
pp. 6C
2011 IOM report recommended “a comprehensive population health- level strategy” to address pain issues
Publication of the National Pain Strategy, guided by the 2011 IOM report
Department of Health and Human Services, National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

15. THE NEED Working Group #1: Population Research
Increase the quantity and quality of what is known about chronic pain within the US population
HHS National Pain Strategy
pp. 4 – A
Improve information on chronic pain prevalence, impact, and treatment
Evaluate population-level interventions
Identify emerging needs
Increase electronic data-gathering
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

16. THE NEED Working Group #2: Prevention and Care
Prevention of acute and chronic pain, especially primary prevention strategies, needs greater emphasis throughout the health care system, including delivery of long-term services and support
HHS National Pain Strategy
pp. 4 – A
Treat chronic pain with comprehensive assessment and creation of an evolving care plan
Strengthen evidence base for pain-prevention strategies, assessment tools, and outcome measures
Improve pain self-management programs
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

17. THE NEED Working Group #3: Disparities
Pain is more prevalent or disabling and/or care is inadequate in certain vulnerable populations
HHS National Pain Strategy
pp. 4 – A
Improve understanding of the impact of bias and strategies to overcome bias
Increase access to high-quality pain care for vulnerable groups
Improve communications between patients and health professionals
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

18. THE NEED Working Group #4: Service Delivery and Payment
Most health care professional education programs do not give pain management adequate attention
HHS National Pain Strategy
pp. 4 – A
A population-based, biopsychosocial approach to pain care, grounded in scientific evidence
Tailoring pain care to an individual patient’s needs
Research and demonstration efforts, building on current knowledge and developing new knowledge
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

19. THE NEED Working Group #5: Professional Education and Training
Variations in clinical practice, individual pain therapies, and inappropriate prescribing of opioids contribute to poor quality care and increase health costs
HHS National Pain Strategy
pp. 4 – A
Improve discipline-specific core competencies (basic knowledge, assessment, team-based care, empathy, cultural competency)
Require pain teaching and clinician learning and undergraduate and graduate levels
Web-based pain education portal with up-to-date and comprehensive educational materials
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

20. The key to transformation in pain care is greater understanding
Working Group #6: Public Education and Communications
THE NEED
The key to transformation in pain care is greater understanding
HHS National Pain Strategy
pp. 4 – A
National public awareness campaign to address misperceptions and stigma concerning pain
Emphasize impact and seriousness of chronic pain (eg, status as a disease requiring treatment)
Educational campaign on safer use of pain medications
National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

21. Office of the Assistant Secretary for Health (OASH)
IMPLEMENTATION OF THE NPS WORKING GROUP RECOMMENDATIONS
Sustained efforts across HHS
Operating divisions
Staff divisions
Nongovernmental partners
IMPLEMENTATION AND EVALUATION PLAN
DHHS
pp. 6B
Prevention of pain
Improvement of patient care and outcomes
Appropriate patient and provider education
Advancement of pain-related applied research
Office of the Assistant Secretary for Health (OASH)
Department of Health and Human Services, National Pain Strategy: A Comprehensive Population Health-Level Strategy for Pain

22. Based on what you have learned, what are your perceptions of the national pain strategy?
WHAT DOES THIS MEAN FOR THE FUTURE OF PAIN MANAGEMENT?

23. THE NPS IS HELPING DRIVE NEW AREAS OF CLINICAL DEVELOPMENT
WHAT DOES THE NPS MEAN FOR THE FUTURE OF PAIN MEDICINE?
“The implementation of the National Pain Strategy will lead to tangible benefits to people suffering from pain. It won’t happen overnight, but this strategy will point us in a proper direction moving forward. It will help to ensure, among other things, that we better educate the health care providers, psychologists, and physical therapists who are caring for people with pain so that they are better prepared to help manage these complex conditions. Ultimately it will lead toward providing people who are suffering from pain the wide range of services that already exist but that currently are not readily available to everyone.”
Sean Mackey, MD, PhD
DHHS
pp. 6B
THE NPS IS HELPING DRIVE NEW AREAS OF CLINICAL DEVELOPMENT
Resolving the Conflict between the Pain Epidemic and the Opioid Crisis
Lynn Webster, MD, remarks that a cautious majority is aware of the drawbacks of opioids but intent on taking a measured approach to the problem
Recategorizing Pain While Exploring Novel Targets
Identifying new ways of defining pain— a recategorization more in line with an individualized approach to pain management.
Discovering compounds that are safer than opioids but still provide significant pain relief to fairly broad patient populations
Developing an Integrated Approach to Undertreatment of Pain
Many patients continue to receive ineffective treatments or are unable to gain access to appropriate treatment
This suffering results in greater medical costs, loss of productivity, and a significant reduction in quality of life
According to the 2011 IOM report, effectively treating pain is a moral imperative
Worley SL. P T. 2016;41(2):

24. AN OVERVIEW:
CDC Guideline for Prescribing Opioids for Chronic Pain

25. GUIDELINE DEVELOPMENT
IMPLEMENTATION OF THE CDC GUIDELINE
TARGET AUDIENCE
Primary care clinicians (eg, family and internists) who are treating patients with chronic pain (ie, pain lasting >3 months or past the time of normal tissue healing) in outpatient settings
OBJECTIVE
To inform clinicians who are considering prescribing opioid pain medications for patients aged ≥18 years with chronic pain (excluding palliative and end-of-life care)
Dowell
pp. 3A
Dowell
pp. 3B
GUIDELINE DEVELOPMENT
Dowell
pp. 4A
ADVANCED LITERATURE REVIEW
Grading of Recommendations Assessment, Development, and Evaluation (GRADE) Method
Systematic review of scientific evidence
SOLICITATION OF EXPERT OPINION
Stakeholder comment “Core Expert Group” included:
Subject matter experts evaluated as having high scientific standing; appropriate academic and clinical training with relevant clinical experience
Representatives of primary care societies and state agencies
Expert in guideline development methodology
Dowell
pp. 5A
pp. 6A,B,C,D
pp. 7A,B
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

26. RISK ASSESSMENT & MITIGATION EFFECTIVENESS OF OPIATES IN ACUTE PAIN
THE CDC GUIDELINE ADDRESSES FIVE PRINCIPAL CLINICAL QUESTIONS
Effectiveness of long- term opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for long-term (≥1 year) outcomes related to pain, function, and quality of life
EFFECTIVENESS
Risks of opioids versus placebo or no opioids on abuse, addiction, overdose, and other harms
THE RISKS
Comparative effectiveness of opioid dosing strategies
IR vs ER (same molecule)
IR vs ER (different molecule)
Immediate release + ER vs IR/ER opioids alone
DOSING STRATEGIES
Accuracy of instruments for predicting risk for opioid overdose, addiction, abuse, or misuse
The effectiveness of risk-mitigation strategies
RISK ASSESSMENT & MITIGATION
Effects of prescribing opioid therapy vs not prescribing opioid therapy for acute pain on long-term use
EFFECTIVENESS OF OPIATES IN ACUTE PAIN
Dowell
pp. 8A
Speaker Notes
Effectiveness: How effectiveness varies according to the type/cause of pain, patient demographics, and patient comorbidities
The Risks: How harms vary according to the type/cause of pain, patient demographics, patient comorbidities, and dose
Dosing Strategies:
Methods for initiating and titrating opioids
IR vs. ER/LA opioids; IR + ER/LA opioids vs. ER/LA opioids alone
Scheduled vs. as-needed dosing; escalation vs. maintenance; rotation vs. maintenance
Treating acute exacerbations of pain
Tapering vs. continuation; different tapering strategies
Risk Assessment & Mitigation:
Effectiveness of risk mitigation strategies (eg, opioid management plans, patient education, urine drug testing, PDMP data, monitoring instruments, monitoring intervals, and abuse-deterrent formulations)
Effectiveness of treatment strategies for patients with addiction
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

27. THE RECOMMENDATIONS OF THE CDC GUIDELINE ARE GROUPED INTO 3 CATEGORIES
Dowell
pp. 15A
Dowell
pp. 15B
Determining when to initiate or continue opioids for chronic pain 1
Opioid selection, dosage, duration, follow-up, and discontinuation 2
Assessing risk and addressing potential harms of opioid use 3
*Outcomes examined at least 1 year later (with most placebo-controlled randomized trials ≤6 weeks in duration) Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

28. RECOMMENDATIONS: DETERMINING WHEN TO INITIATE OR CONTINUE OPIOID THERAPY FOR CHRONIC PAIN
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred
Consider opioid therapy only if benefits for pain and function are anticipated to outweigh risks
If opioids are used, they should be combined with nonpharmacologic and nonopioid pharmacologic therapy 1
Dowell
Box 1
pp.16
Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients
Realistic goals for pain and function
How will therapy be discontinued if benefits do not outweigh risks?
Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety 2
Discuss known risks and benefits of opioid therapy and patient/clinician responsibilities for managing therapy 3
Dowell D, et al. MMWR Recomm Rep. 2016;65(1):1-49.

29. RECOMMENDATIONS: OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, AND DISCONTINUATION4
When starting opioid therapy, clinicians should prescribe IR opioids instead of ER/LA opioid
When starting opioid therapy, clinicians should prescribe lowest effective dosage
Use caution at any dosage
Reassess benefits and risks when dosing ≥50 morphine milligram equivalents (MME)/day
Avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day 5
Dowell
Box 1
pp.16
Long-term opioid use often begins with treatment of acute pain
When opioids are used for acute pain, prescribe the lowest effective dose of IR opioids
Prescribe no more than needed for the duration of pain severe enough to require opioids
≤3 days is often sufficient; >7 days is rarely necessary 6
Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy or dose escalation 7
Dowell D, et al. MMWR Recomm Rep. 2016;65(1):1-49.

30. RECOMMENDATIONS: ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE8
Evaluate risk factors for opioid-related harm
Dowell
Box 1
pp.16
Review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data 9
Use urine drug testing before starting opioid therapy
Consider annual urine drug testing 10
Dowell D, et al. MMWR Recomm Rep. 2016;65(1):1-49.

31. RECOMMENDATIONS: ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE (CONTINUED)
Dowell
Box 1
pp.16 11
Avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible
Offer or arrange evidence-based treatment for patients with opioid use disorder
Usually medication-assisted treatment with buprenorphine or methadone with behavioral therapies 12
Dowell D, et al. MMWR Recomm Rep. 2016;65(1):1-49.

32. Navigating the Evolving Landscape From the CDC Guideline

33. These resources, and many more, are available at
CDC PROVIDES EDUCATIONAL TOOLS, BROCHURES, AND VISUAL AIDS TO ASSIST WITH IMPLEMENTATION OF CDC GUIDELINE RECOMMENDATIONS
Tapering pocket guide
Fact sheet
Checklist
Nonopioid treatments
Calculating dosage
CDC
pp. 1A
pp. 2A,B
Dowell
pp. 34A
These resources, and many more, are available at
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

34. ADJUSTING CLINICAL PRACTICE TO INCORPORATE THE CDC GUIDELINE
Established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety- provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence.
These patients should be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk.
Clinicians should explain to patients taking high opioid dosages (≥90 MME/day) that there is now an established body of scientific evidence showing that overdose risk is increased at higher opioid dosages.
Clinicians should empathically review benefits and risks of continued high-dosage opioid therapy and should offer to work with the patient to taper opioids to safer dosages.
For patients who agree to taper opioids to lower dosages, clinicians should collaborate with the patient on a tapering plan (Recommendation 7).
Patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.
Clinicians should remain alert to signs of anxiety, depression, and opioid use disorder (Recommendations 8 and 12) that might be unmasked by an opioid taper and arrange for management of these comorbidities.
For patients agreeing to taper to lower opioid dosages as well as for those remaining on high opioid dosages, clinicians should establish goals with the patient for continued opioid therapy (Recommendation 2), maximize pain treatment with nonpharmacologic and nonopioid pharmacologic treatments as appropriate (Recommendation 1), and consider consulting a pain specialist as needed to assist with pain management.
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

35. AAPM HAS RAISED CONCERNS WITH THE GUIDELINE
The CDC guideline for prescribing opioids for chronic pain could be a useful tool for practitioners. However, the American Academy of Pain Medicine says there are serious issues with the guideline that need to be addressed.
Practical Pain Management
pp. 2
The CDC guideline may negatively impact the quality of patient care, as the recommendations seem to be more focused on “mitigation of societal risk in response to an epidemic of opioid misuse and abuse, as opposed to quality evidence-based clinical management of pain.”
Practical Pain Management, AAPM Raise Concerns Over CDC Guidelines. Accessed October 25, 2016.

36. Patient feedback After release of the CDC guideline
PRACTICING IN THIS NEW ENVIRONMENT AND CONTINUING TO DELIVER ADEQUATE PATIENT CARE is a challenge
A TOTAL OF 1,978 PATIENTS PARTICIPATED IN THE SURVEY, WHICH WAS CONDUCTED THROUGH SOCIAL MEDIA AND ONLINE SUPPORT GROUPS
Over 68% of patients said their opioid pain medication has been decreased or discontinued since the guideline recommendations were released in March
Nearly 45% were warned by their doctor that additional decreases will be necessary
75% of patients said they are not receiving adequate pain control
57% said they had been discharged or abandoned by a doctor because they need opioid treatment
44% said they had problems getting a prescription filled at a pharmacy
90% said their pain levels, activities, and social interactions have worsened
97% said they have never been addicted or required treatment for drug abuse
Pain News Network. Survey: Opioids Reduced or Stopped for Most Patients. Accessed October 5, 2016.

37. How haS the guideline impacted How you CARE FOR PATIENTS WITH CHRONIC PAIN?
how has this impacted your patients’ quality of life?

38. #1 FACT OR FICTION:
THE CDC GUIDELINE IS A FEDERAL LAW PASSED BY CONGRESS AND SIGNED BY THE PRESIDENT
ANSWER: FICTION
EXPLANATION:
“The Guideline is not a rule, regulation, or law. It is not intended to deny access to opioid pain medication as an option for pain management. It is not intended to take away physician discretion and decision-making.”
Debra Houry,  Director of the CDC’s National Center for Injury Prevention
Pain News Network. 5 Myths About the CDC Opioid Guidelines

39. #2 FACT OR FICTION:
THE CDC GUIDELINE RECOMMENDATIONS WERE MADE BASED ON SURVEY RESPONSES FROM PAIN SPECIALISTS
ANSWER: FICTION
EXPLANATION:
The recommendations described in the CDC guideline were made via systematic review of the best available scientific evidence*, along with input from experts, followed by review and deliberation by a federally chartered advisory committee. The recommendations are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations.
*Note that there is controversy surrounding the quality of the evidence used in developing the CDC guideline.

40. #3 FACT OR FICTION:
THE CDC GUIDELINE RECOMMENDS NONPHARMACOLOGIC TREATMENT AND NONOPIOID PHARMACOLOGIC TREATMENT OVER OPIOID PHARMACOLOGIC TREATMENT
ANSWER: FACT
EXPLANATION:
The CDC guideline states that many nonpharmacologic therapies, including physical therapy, weight loss, and psychological therapy, can reduce chronic pain. Moreover, several nonopioid pharmacologic therapies are effective for chronic pain. These approaches have a superior risk-benefit profile compared to opioid pharmacologic therapy.

41. #4 FACT OR FICTION:
THE CDC GUIDELINE RECOMMENDS MANDATORY UNIVERSAL MONTHLY URINE DRUG TESTING FOR PATIENTS RECEIVING OPIOIDS
ANSWER: FICTION
EXPLANATION:
The CDC guideline states that urine drug testing can provide important information about drug use that is not reported by the patient, as well as assist clinicians in identifying when patients are not taking the opioid prescribed for them. Experts agreed that clinicians should use urine drug testing before initiating opioid therapy, but they disagreed on how frequently urine drug testing should be conducted during long-term opioid therapy. Most experts agreed that annual urine drug testing is reasonable. However, this interval might be too long in some cases and too short in others, and the follow-up interval should be left to the clinician’s discretion.

42. #5 FACT OR FICTION:
THE CDC GUIDELINE EMPHASIZES DIRECT INVOLVEMENT OF PATIENTS IN DECISION-MAKING ABOUT STARTING THEIR OPIOID THERAPY
ANSWER: FACT
EXPLANATION:
The CDC guideline states that clinicians should involve patients in decisions regarding whether to start or continue opioid therapy. Given the potentially serious risks of long-term opioid therapy, the guideline encourages clinicians to ensure that patients are aware of the potential benefits of, harms of, and alternatives to opioids before starting or continuing opioid therapy. The guideline also encourages clinicians to have open and honest discussions with patients to inform mutual decisions about whether to start or continue opioid therapy.

43. #6 FACT OR FICTION:
THE CDC GUIDELINE STRONGLY DISCOURAGES CONCURRENT PRESCRIBING OF OPIOIDS AND BENZODIAZEPINES
ANSWER: FACT
EXPLANATION:
The CDC guideline warns that opioids and benzodiazepines cause central nervous system depression and can decrease respiratory drive. Therefore, concurrent use of these products puts patients at greater risk of potentially fatal overdose.
The FDA now requires boxed warnings and patient-focused medication guides for prescription opioids, opioid-containing cough products, and benzodiazepines, with information about the serious risks associated with concurrent use of these medications.

44. Identifying Appropriate Use for Extended-Release Opioids

45. THE CDC GUIDELINE PROVIDES SPECIFIC DIRECTION FOR RESPONSIBLE OPIOID PRESCRIBING IN REAL-WORLD PRACTICE
Dowell
pp. 21B
pp. 22C
pp. 24A
pp. 31B
OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, AND DISCONTINUATION
Recommendation #4: When starting opioid therapy, clinicians should prescribe IR opioids instead of ER/LA opioids
Recommendation #5: When starting opioid therapy, clinicians should prescribe the lowest effective dosage
Recommendation #6: When opioids are used for acute pain, IR opioids should be prescribed at the lowest effective dose
ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE
Recommendation #11: Clinicians should not prescribe opioids and benzodiazepines concurrently
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

46. WHO ARE APPROPRIATE CANDIDATES FOR ER/LA OPIOIDS?
RECOMMENDATION #4 OF THE CDC GUIDELINE ADDRESSES APPROPRIATE USAGE OF ER/LA OPIOIDS
Dowell
pp. 21C
WHO ARE APPROPRIATE CANDIDATES FOR ER/LA OPIOIDS?
ER/LA opioids should be reserved for “management of pain severe enough to require daily, around-the-clock, long-term opioid treatment” when “alternative treatment options... are ineffective, not tolerated, or would be otherwise inadequate to provide sufficient management of pain” and not used as “as needed” pain relievers
ER/LA opioids are only appropriate for opioid-tolerant patients (ie, patients who have received certain dosages of opioids [eg, 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids]) for ≥1 week
Dowell D, Haegerich TM, Chou R. MMWR Recomm Rep. 2016;65(1):1-49.

47. WHAT IS THE ROLE OF THE PRIMARY CARE PROVIDER IN PRESCRIBING ER/LA OPIOIDS?
WHEN SHOULD THE PATIENT BE REFERRED TO A PAIN MANAGEMENT SPECIALIST?

48. Thank you!
QUESTIONS?