CDC’S OPIOID PRESCRIBING GUIDELINES APPLIED TO NATIVE COMMUNITIES

The CDC has released guidelines for prescribing opioids safely. The full guidelines may be accessed through the Resources section of this pocketbook. A quick overview is provided below, with a few additional considerations for Native communities. Please note that cancer patients, sickle cell patients, and other palliative care patients are largely exempt from these guidelines.

Before prescribing opioids, providers should do the following:

+ Consider that patients may feel pain reflected through social and spiritual qualities. Native patients may feel that their pain cannot be adequately reflected in a number or fixed pain descriptor (Jimenez et al., 2011). Listen to the patient’s story. Practicing active listening during the patient’s story increases connection and aids with associating a number or descriptor.

+ Consider how mental health is impacting pain. Providers should give all patients baseline and intermittent depression and anxiety screenings. Mental health challenges can make painful conditions worse (de Heer et al., 2014; Murez, 2021).

+ Use nonjudgmental language when talking to patients. Some patients may worry about facing judgment for their pain (Duwe, 2019). Racial bias in pain management has been documented; Black patients are less likely than White patients to receive pain medication (Trawalter, 2020). This disparity is particularly pronounced when the patient has a subjective condition such as low back pain or migraines instead of an objective injury (e.g., compound fracture; Tamayo-Sarver et al., 2003). These disparities may exist because of false beliefs about Black people’s pain tolerance and due to racist bias that they are more likely to be drug seeking (Warraich, 2020). Native American patients may be experiencing the same disparities. As Duwe (2019) noted, Native chronic pain patients feel that stereotypes about Native American stoicism can affect behavior. One patient said, “[Because of stereotypes,] I don’t look like I’m in pain. I look strong because I try to look strong. I don’t want to be looking all bent over and pitiful like I can’t, that I’m weak” (Duwe, 2019). A Native woman reflected on her pain by saying, “I think there’s kind of an expectation that we’re going to handle it and keep going” (Duwe, 2019). Using nonjudgmental language will help foster an open and trusting patient–provider relationship in which patients receive the best care possible.

+ Remember that nonpharmacologic and nonopioid therapies are preferred. If opioids are needed, combine their use with nonpharmacologic and nonopioid therapies (Dowell et al., 2016). Talk to the patient about their relationship with traditional healing and consider drug interactions.

+ Consider the benefits and risk of opioids for the patient. Discuss options for pain management with the patient and when appropriate, key family members. Treatment decisions should be based on shared decision-making. Consider opioids only if the benefits for pain and function outweigh the risks to the patient (Dowell et al., 2016). The Opioid Risk Tool (Figure 1) is indicated in primary care settings to assess risks for opioid abuse among individuals prescribed opioids for chronic pain. The assessment takes less than 1 minute to administer. The tool is also listed in the Resources section of this pocketbook.

Opioid Risk Tool: A survey to assess risk of opioid abuse

Note. This questionnaire was developed to assess the risk of opioid addiction. “Predicting Aberrant Behaviors in Opioid-Treated Patients: Preliminary Validation of the Opioid Risk Tool,” by L. R. Webster and R. Webster, 2005, Pain Medicine Journal, 6(6), p. 432.

This tool should be administered to patients upon an initial visit prior to beginning opioid therapy for pain management. A score of 3 or lower indicates low risk for future opioid abuse, a score of 4 to 7 indicates moderate risk for opioid abuse, and a score of 8 or higher indicates a high risk for opioid abuse.

Mark each box that applies

Family history of substance abuse

Alcohol Illegal drugs

Rx drugs

Personal history of substance abuse

Alcohol Illegal drugs

Rx drugs

Age between 16-45 years

History of peradolescent sexual abuse

Psychological disease

ADD, OCD, bipolar, schizophrenia

Depression

Scoring totals

Establish treatment goals before starting opioids (e.g., realistic goals for pain and functions). Include realistic goals for pain and function and determine how the opioid therapy will be discontinued if the benefits do not outweigh the risks (Dowell et al., 2016). The chart in Figure 2 can be used to facilitate these conversations.

Functional Goals for Chronic Pain Treatment

Note. Adapted from “Functional Goals,” by American Association of Family Physicians, n.d., Chronic Pain Management Toolkit, Section 2, p. 16.

Functional Goals for Chronic Pain Treatment

Adapted from “Functional Goals,” by American Association of Family Physicians, n.d., Chronic Pain Management Toolkit, Section 2, p. 16.

What activities are limited due to pain?

Limited Action

walking exercise sleep sexual activity work house work community responsibilities family and friend relationships self-care (bathing, dressing, eating) cultural activities caretaking other: _______________________

What activities are most important?

Write them here...

Goal

Provider and patient can complete the action plan together:

Treatment Plan

OPIOID SELECTION, DOSAGE, AND DURATION

(Dowell et al., 2016)

+ Immediate-release opioids are preferred to extendedrelease or long-acting opioids.

+ Prescribe the lowesteffective dosage.

+ Prescribe no greater quantity than needed. Three or fewer days is often sufficient; more than 7 days is rarely needed to manage acute pain.

+ Carefully reassess individual benefits and risks when considering increasing dosage to over 50 MME/day.

+ Avoid doses greater than 50 MME/day or carefully justify any decision to titrate the dosage to over 90 MME/day.

+ Prescribe naloxone for chronic pain patients and for patients at high risk of opioid overdose (see Figure 3).

Promotional

flyer for Narcan nasal spray

Note. Flyer available at https://www. spthb.org/resources/publications/.