Event 3: CDC Guidelines

Essence of CDC "Guidelines"

In response to the opioid epidemic, the CDC released guidelines for prescribing opioids for chronic pain. They recognized increased potential for harm when opioids and benzodiazepines are prescribed concurrently and recommended that clinicians avoid prescribing these medicines together.

• Doesn't relate to cancer, end-of-life or institutional use
• Focus is on RISK of medication use
• Exhaust all non-opioid options
• Trust but verify (do Prescription Drug Monitoring Program (PDMP searches)
• Don't mix with other depressants (benzodiazepines)
• Risks go up after 50 Morphine Milligram Equivalence (MME)/day
  • Counsel and give naloxone injector
• Don't exceed 90 MME/day
• Limit duration of treatment

Here is a quick reference for healthcare providers on balancing pain management with the potential risks posed by prescription opioids.

Mrs. Wright's Benzodiazepine Prescription

Andrew raises concerns about Mrs. Wright's benzodiazepine prescription mixing in a dangerous way with opioids she's given.

Mrs. Wright's concurrent use of opioids and benzodiazepines adds to the complexity of her care.

Test Your Knowledge

Which medication interacts with opioids to cause unintended depression most frequently?

Update on Mrs. Wright's Pain

Practice Conversion

What is the calculated oral morphine equivalent dose of 12mg IV Dilaudid?

Adjusting for Well Controlled Pain 

Practice Conversion

First Conversion

What would be an appropriate dose of oxycodone for Mrs. Wright?

Second Conversion

Please convert 4mg IV Dilaudid to oral morphine equivalents (OME).

Third Conversion

Please convert 300 OME to IV Dilaudid.

Fourth Conversion

Please convert 10mg PO oxycodone to PO hydrocodone.

Mrs. Wright's Discharge Medications

What should Mrs. Wright's discharge medications look like?

• Oxycontin 20mg BID
• Oxycodone 10mg every 4 hours
• Clonazepam 1mg TID PRN anxiety. This is Mrs. Wright's home medication, but the dose should be decreased with the suggestion that she taper off this medication with high dose opioids, per CDC guidelines.

Avoid high dose Gabapentin in geriatric patients (E.G., Gabapentin 1200mg TID for Mrs. Wright would not be ideal.)

Avoid Ambien in geriatric patients because it may cause sedation and confusion (E.G., Ambien 10mg QHS for Mrs. Wright would not be ideal.)

Avoid Zanaflex (E.G., 6mg TID) as it can cause significant sedation and confusion, without adding much analgesia.

Sending Mrs. Wright home with Norco 10mg/325mg every 4 hours would provide inadequate pain control based on calculations and the plan for Mrs. Wright previously discussed.

Practice Conversion

First Conversion

How do we convert Mrs. Wright's discharge medications of 100mg oxycodone to oral morphine equivalents?

Discharging Mrs. Wright

The CDC recommends a prescription of Naloxone, a drug that can reverse the effects of opioid overdose in situations where a person is taking higher opioid dosages or taking benzodiazepines concurrently.

Test Your Knowledge

What can be prescribed to Mrs. Wright to help with the concern of her high OME and benzodiazepine use?

Meeting With Mrs. Wright About Her Discharge Pain Medication

Test Your Knowledge

Question 1

What modalities should decrease the patient's need for increased opioids post-procedure?

Question 2

All of the following could contribute to the medical complexity of a patient's use of opioids EXCEPT:

Question 3

Which medicine would you be most concerned about a patient taking with opioids?

Question 4

You have a patient being discharged home on long-acting opioids. The CDC recommends which of the following medication are also prescribed upon discharge for safety reason:

Question 5

When you are discharging a patient taking chronic opioids and who sees a chronic pain physician, what would be most important to consider?