What are the recommendations for opioid use in rural populations?

From the Guidelines

Opioid use in rural populations should be approached with caution, prioritizing non-opioid alternatives and reserving opioids for cases where benefits outweigh risks, as recommended by the 2022 CDC clinical practice guideline for prescribing opioids for pain 1. When considering opioid use, it is essential to weigh the potential benefits against the risks, including opioid use disorder, overdose, and death. The 2022 CDC guideline emphasizes the importance of a multimodal and multidisciplinary approach to pain management, attending to the physical health, behavioral health, and long-term services and supports of each person. Key recommendations for opioid use in rural populations include:

• Implementing comprehensive pain management strategies that emphasize non-opioid alternatives first
• Starting with the lowest effective dose of opioids when necessary, typically beginning at 5-10mg every 4-6 hours as needed, with close monitoring and regular reassessment
• Establishing clear prescribing protocols, utilizing prescription drug monitoring programs, and incorporating telehealth for specialist consultation and follow-up care
• Educating providers and patients about proper opioid use, storage, and disposal, as well as expanding access to naloxone for overdose prevention
• Providing treatment for opioid use disorder through medication-assisted treatment with buprenorphine or methadone These recommendations are supported by the 2022 CDC guideline, which emphasizes the importance of individualized, person-centered care and flexibility to meet the unique needs of each patient 1. The guideline also highlights the need for special attention to avoid misapplying the guideline beyond its intended use or implementing policies purportedly derived from it. In contrast to the 2016 CDC guideline, which focused on chronic pain management, the 2022 guideline provides recommendations for acute, subacute, and chronic pain management, recognizing the complexity and variability of pain experiences 1. However, the core principles of prioritizing non-opioid alternatives and reserving opioids for cases where benefits outweigh risks remain consistent across both guidelines.

From the FDA Drug Label

As an opioid, buprenorphine hydrochloride exposes users to the risks of addiction, abuse, and misuse. Although the risk of addiction in any individual is unknown, it can occur in patients appropriately prescribed buprenorphine hydrochloride

Assess each patient's risk for opioid addiction, abuse, or misuse prior to prescribing buprenorphine hydrochloride, and reassess all patients receiving buprenorphine hydrochloride for the development of these behaviors and conditions

Risks are increased in patients with a personal or family history of substance abuse (including drug or alcohol addiction or abuse) or mental illness (e.g., major depression).

The FDA drug label does not answer the question about recommendations for opioid use in rural populations. 2 2

From the Research

Opioid Use in Rural Populations

• Rural residents with chronic pain are more likely to receive an opioid prescription than nonrural residents 3
• The use of self-management interventions for chronic pain management is less common among rural residents compared to nonrural residents 3
• Demographic variables such as age, sex, and ethnicity do not influence the healthcare use or prescription of opioids in rural residents with chronic pain 4
• Depressive symptoms and a diagnosis of depression are associated with increased healthcare use and prescription of opioids in rural residents with chronic pain 4

Recommendations for Opioid Use

• Screening for depression is advised as part of the standard care of patients with pain, ideally with follow-up assessments and treatment of depression as necessary 4
• Making psychosocial interventions more available at rural healthcare centers may help in lowering psychological distress, which may have the ultimate effect of reducing opioid prescriptions for rural residents with chronic pain 4
• Nurses can play an essential role in addressing the disparity in the use of self-management interventions for chronic pain management by educating patients about self-management interventions 3
• Proper patient screening, education, and preemptive treatment of potential side effects may aid in maximizing effectiveness while reducing the severity of side effects and adverse events associated with opioid use 5

Challenges and Considerations

• The lack of access to specialists and pain management training of primary care providers may contribute to the disparity in the use of self-management interventions for chronic pain management in rural residents 3
• Restrictive prescription measures implemented in response to the opioid crisis may have consequences similar to prohibitionist policies, heightening overdose risks for people who use drugs by increasing exposure to street drugs laced with fentanyl 6
• Improving access to diverse chronic pain management options can help reduce harms related to street-opioid use 6