Hard thresholds for pain medication doses and duration are no longer promoted through the CDC's new Clinical Practice Guideline for Prescribing Opioids for Pain.
The new guidance -- which covers acute, subacute, and chronic pain for primary care and other clinicians -- updates and replaces the controversial 2016 CDC opioid guideline for chronic pain. The 2016 guideline was interpreted as imposing strict opioid dose and duration limits and was misapplied by some organizations, leading the guideline authors to clarify their recommendations in 2019.
The 2022 recommendations are voluntary and give clinicians and patients flexibility to support individual care, said Christopher Jones, PharmD, DrPH, MPH, acting director of CDC's National Center for Injury Prevention and Control in a CDC press briefing. They should not be used as an inflexible, one-size-fits-all policy or law, or applied as a rigid standard of care, or replace clinical judgement about personalized treatment, he emphasized.
"Patients with pain should receive compassionate, safe, and effective pain care," Jones stated. "We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life."
The guidance, published in Morbidity and Mortality Weekly Report, addresses four key areas: initiating opioids for pain, selecting opioids and dosages, deciding prescription duration and conducting follow-up, and assessing risk and potential harms of opioids. It suggests that clinicians work with patients to incorporate plans to mitigate risks, including offering naloxone.
The 100-page document indicates opioids should not be considered as first-line or routine therapy for subacute or chronic pain, and points out that non-opioid therapies often are better for many types of acute pain.
"For patients receiving opioids for 1 to 3 months (the timeframe for subacute pain), the 2022 guideline recommends that clinicians avoid continuing opioid treatment without carefully reassessing treatment goals, benefits, and risks in order to prevent unintentional initiation of long-term opioid therapy," wrote Debbie Dowell, MD, MPH, chief clinical research officer for CDC's Division of Overdose Prevention, and guideline co-authors in a commentary published in the New England Journal of Medicine.
For chronic pain, clinicians should maximize use of non-opioid therapies and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks, Dowell and colleagues noted. When opioids are needed for chronic pain, clinicians should start at the lowest effective dose, evaluate benefits and risks before increasing dosage, and avoid raising dosage above levels likely to yield diminishing returns, they added.
"These principles do not imply that nonpharmacologic and non-opioid pharmacologic therapies must all be tried unsuccessfully in every patient before opioid therapy is offered," Dowell and colleagues wrote. "Rather, expected benefits specific to the clinical context should be weighed against risks before therapy is initiated."
The new guideline offers tips for tapering opioids when warranted, but is not intended to lead to rapid opioid tapering or discontinuation, Jones noted. The recommendations do not apply to sickle cell disease-related pain, cancer pain, and palliative or end-of-life care.
The 2022 document incorporated feedback from approximately 5,500 public comments since the new version was first proposed in February, including reactions from people who discussed their experiences with pain or opioid addiction and barriers to pain care. An independent federal advisory committee, four peer reviewers, and members of the public reviewed the draft version.
"The science on pain care has advanced over the past 6 years. During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians," Dowell said in a statement. "We've been able to improve and expand our recommendations by incorporating new data with a better understanding of people's lived experiences and the challenges they face when managing pain and pain care."
The clinical practice guideline supports the HHS Overdose Prevention Strategy, the CDC said. The agency also is providing additional information associated with the guideline to clinicians and patients.
Disclosures
The authors reported no disclosures.
Primary Source
Morbidity and Mortality Weekly Report
Source Reference: Dowell D, et al "CDC Clinical Practice Guideline for Prescribing Opioids for Pain -- United States, 2022" MMWR 2002, DOI: 10.15585/mmwr.rr7103a1.
Secondary Source
New England Journal of Medicine
Source Reference: Dowell D, et al "Prescribing opioids for pain -- the new CDC clinical practice guidelines" N Engl J Med 2022; DOI: 10.1056/NEJMp2211040.
