CDC Recommendations

Regular face-to-face visits with the patient and evaluation of progress against goals should be scheduled during the period when the opioid dosage is being adjusted. The opioid trial or long-term treatment should be continually evaluated for functional benefit and achievement of treatment goals, using appropriate tracking tools.

Clinically meaningful improvement has been defined as a 30% improvement in scores for both pain and function. Monitoring progress toward patient-centered functional goals (walking the dog or walking around the block, returning to part-time work, attending family sports or recreational activities) can also contribute to the assessment of functional improvement. Prescribing providers should use these goals in assessing the benefits of opioid therapy for individual patients and in weighing benefits against risks of continued opioid therapy.

There are a variety of tracking tools that can be used to set and monitor treatment goals:

- Pain Assessment and Documentation Tool (PADT™)
- Brief Pain Inventory (BPI©)
- Treatment agreement
- Patient Health Questionnaire (PHQ-4 or PHQ-9)

Parenteral (intravenous, intramuscular, or subcutaneous) administration of opioids for chronic pain is strongly discouraged, unless prescribing within an inpatient or palliative care setting.

Any circumstance warranting parenteral administration should be clearly justified by clinical exigencies (bowel obstruction, terminal care, etc.).

These guidelines do not consider intrathecal administration and this recommendation was not intended to discourage trained and qualified physicians from using intrathecal opioid medications when indicated.

Daily intramuscular (IM) or subcutaneous (SC) injections should be avoided except in a highly supervised environment, such as during an admission to the hospital or hospice.

Once a stable dose has been established, regular monitoring should be conducted at face-to-face visits. During these visits, treatment goals, affect and mood, analgesia, activity and level of function, adverse effects, and aberrant behaviors should be monitored. These assessments can be remembered as the “5 A’s.”

Medication adjustments, if necessary, should be made and prescriptions provided during a clinic visit. Face-to-face follow-up visits should occur at least every two to four weeks during any period when dosages are being adjusted. More frequent follow-up visits may be advisable when prescribing opioid medication to a patient with a known addiction problem, suspected aberrant behavior, or co-existing psychiatric or medical problems.

Options for medication adjustments include reducing medication or rotating opioid medication. Opioid rotation can be an effective means of reducing opioid dose, reducing adverse side effects or improving efficacy. However, when switching from one opioid to another, extreme caution is required due to incomplete cross-tolerance among various opioids. Refer to opioid rotation guidelines before attempting an opioid switch (opioid rotation). When it is documented that the patient is compliant with agreed-upon recommendations, the prescriber may consider adding supplemental immediate release/ short-acting (IR/SA) medications for control of break-through pain exacerbation to facilitate increases in activity.

In general, if the patient’s underlying medical condition is chronic and unchanging and if opioid associated problems (hyperalgesia, substantial tolerance, important adverse effects) have not developed, it is recommended that the effective dose achieved through titration not be lowered once the patient has reached a plateau of adequate pain relief and functional level.