Six years after publishing their first set of opioid prescribing guidelines, the Centers for Disease Control and Prevention (CDC) have published an updated Clinical Practice Guideline for Prescribing Opioids.
The CDC states that while several laws, regulations, and policies that support recommendations from the 2016 guidelines had positive results for patients, the 2016 recommendations were meant to be voluntary and flexible to support individualized patient-centered care.
The CDC believes that their 2016 guidelines were misapplied in certain scenarios, including untreated and undertreated pain, serious withdrawal symptoms, worsening pain outcomes, psychological distress, overdose, and suicidal ideation and behavior. These points mirror discussions carried out by the American Medical Association (AMA) in 2020, which led the AMA to publish an Opioid Task Force Report.
While the official guidelines are over 100 pages in length, they can be summarized into 12 recommendations for clinicians who are prescribing opioids for outpatients aged 18 and older with acute (a month or less), subacute (one to three months), or chronic (three or more months) pain. These guidelines are broken up into four areas:
- Determining whether or not to initiate opioids for pain
- Selecting opioids and determining dosages
- Deciding duration of initial opioid prescriptions and conducting follow-up
- Assessing risk and addressing potential harms of opioid use
Please note, these guidelines exclude pain related to sickle cell disease, cancer treatment, and palliative and end-of-life care.
Determining Whether or Not to Initiate Opioids for Pain
Recommendation 1 & 2
Nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient.
Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.
*Recommendation #2 is virtually identical to Recommendation #1, applying to subacute and chronic pain, though it must be noted that the supporting literature and research diverges as appropriate.
Selecting Opioids and Determining Dosages
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.
When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage. If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.
For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.
If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages
Deciding Duration of Initial Opioid Prescription and Conducting Follow-Up
When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.
Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients,
Assessing Risk and Addressing Potential Harms of Opioid Use
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients. Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder. Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.