Updated CDC guidelines for prescribing opioids

On November 4, 2022, the United States Centers for Disease Control and Prevention (CDC) updated their clinical practice guidelines for opioid prescription in pain management.

CDC Clinical Practice Guideline for prescribing opioids for pain - United States, 2022. Centers for Disease Control and Prevention. Image Credit: Victor Moussa / Shutterstock.com

CDC Clinical Practice Guideline for prescribing opioids for pain - United States, 2022. Centers for Disease Control and Prevention. Image Credit: Victor Moussa / Shutterstock.com

The importance of pain management

Pain is one of the four cardinal signs of inflammation, in addition to inflammation, swelling, and loss of function. Pain remains one of the most common complaints for adults seeking medical care in the U.S.

Pain can be classified as acute, sub-acute, or chronic pain. Whereas acute pain is present for less than one month, sub-acute and chronic pain typically have durations for one to three months and more than three months, respectively.

Pain, particularly chronic pain, significantly affects an individual’s quality of life, as well as their physical and emotional health. In fact, between 2003 and 2014, about 9% of suicides had a history of chronic pain; however, this is likely an underestimate.

Taken together, the wide range of adverse effects associated with chronic pain emphasize the importance of the adequate prevention, assessment, and treatment of pain. Furthermore, pain management should be a holistic process that considers the possible reversible causes of the patient’s pain, as well as both pharmacologic and nonpharmacologic treatment options.

The risks of opioids

Opioids are common pharmacological agents that are used to manage pain; however, the long-term use of these agents increases the risk of overdose and misuse. Notably, both immediate- and extended-release opioids have been associated with an increased risk of addiction, abuse, misuse, overdose, and death.

Between 1999 and 2010, the rate of opioid prescriptions within the U.S. increased by four-fold, which subsequently led to a significant rise in opioid use disorders and overdose deaths involving prescription opioids. In addition to a greater overall volume of opioids prescribed during this time, opioids were also prescribed at higher doses and for longer durations in patients, despite the lack of evidence supporting the long-term effectiveness of opioids in the management of chronic pain.

Updated opioid prescription guidelines

In an effort to reduce the adverse effects associated with opioid use, as well as promote the appropriate prescription of these highly addictive drugs, the U.S. CDC Guideline for Prescribing Opioids for Chronic Pain was originally published in 2016. On November 4, 2022, the CDC updated these guidelines to better help clinicians provide informed and personalized pain care to patients.

The priority for managing acute pain is using non-opioid therapies. However, opioid therapy should be considered if the benefits outweigh the risks. Thus, it is imperative that clinicians inform their patients about the benefits and potential risks associated with opioids before initiating treatment.

If the patient is suffering from sub-acute and chronic pain, non-opioid therapies are preferred. Although the use of non-opioid therapies is a priority, prescribing opioids may be considered if the expected benefits outweigh the potential risks.

Immediate-release opioids are preferred over extended-release and long-acting opioids to treat any type of pain.

In patients who have not previously been prescribed an opioid, clinicians should start with the lowest dose that will effectively manage their pain. In patients suffering from chronic or sub-acute pain, the opioid dosage must be carefully selected. 

If the clinician decides to increase the opioid dose for their patients, the individualized risks and benefits should be evaluated and appropriate doses should be prescribed, such that the benefits outweigh the risks.

In cases with acute pain warranting opioid use, only the quantity of opioids necessary for the expected pain duration must be prescribed.

If the clinician prescribing opioids for chronic or sub-acute pain has increased the dose, the risks and benefits should be evaluated within one-to-four weeks. Even after this reassessment point, the risks and benefits must be regularly evaluated and discussed with patients receiving opioid therapy.

Clinicians should assess the side effects of opioid use before and periodically after commencing opioid therapy, as well as periodically discuss the risks of opioid therapy with their patients. Any strategy to reduce the risks of opioid use, including the use of naloxone, must also be discussed.

Before prescribing opioids for any type of pain, clinicians should enquire in detail about the patient’s medical and drug history, past substance abuse, history of overdose, and current use of another central nervous system (CNS) depressant.

Clinicians should remain cautious while prescribing opioids to patients on CNS depressants like benzodiazepines. When concurrent use is indicated, the clinician must evaluate the associated risks against the proposed benefits.

When prescribing opioids for chronic or sub-acute pain, the risks and benefits of toxicology testing should be considered to assess the prescribed opioid dose when used along with other non-prescribed or prescribed controlled substances.

Treatment planning must incorporate evidence-based medications for treating patients suffering from opioid use disorder. Non-pharmacological detoxification of opioid use disorder is not recommended, as it increases the risk of overdose, drug relapse, and overdose-associated fatalities.

Conclusions

The updated CDC guidelines offer effective and safe pain management with apt therapeutic strategy discussions with patients. Thus, these guidelines will aid in the customization of pain management strategies to ultimately improve the quality of life of patients suffering from any type of pain.

Journal reference:
  • Dowell, D., Ragan, K. R., Jones, C. M., et al. (2022). CDC Clinical Practice Guideline for prescribing opioids for pain - United States, 2022. Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report 71(No. RR-3);1-95. doi:10.15585/mmwr.rr7103a1.
Nidhi Saha

Written by

Nidhi Saha

I am a medical content writer and editor. My interests lie in public health awareness and medical communication. I have worked as a clinical dentist and as a consultant research writer in an Indian medical publishing house. It is my constant endeavor is to update knowledge on newer treatment modalities relating to various medical fields. I have also aided in proofreading and publication of manuscripts in accredited medical journals. I like to sketch, read and listen to music in my leisure time.

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Comments

  1. Jennifer Eulate Jennifer Eulate United States says:

    What about patients allergic to all NSAIDS ? What will we take for chronic pain relief? Antidepressants DO NOT help

    • C Collier C Collier United States says:

      As a chronic pain sufferer, I was diagnosed with a GI bleed from using ibuprofen daily back in 2009. The only option for pain relief was opiates. They gave me some quality of life back. I really wish they’d stop lumping us all into the addict category. I’d rather take ibuprofen which helps my pain the best, but I’d rather not die if internal bleeding or CKD. Just let us get relief please.

  2. Loraine Harnisch Loraine Harnisch United States says:

    It is exactly this attitude that cost me 2.5 years of my life. After moving in July 2020 I resumed care at the practice I had been previously working with in Illinois.  During the 8 years in Alabama,  I worked with my physician carefully reducing my opioid dosage to the minimum required for adequate pain management. I was able to take walks maintain my household responsibilities such as shopping,  cooking,  laundry,  etc. Upon returning to Illinois my medication regimen was reduced by 50% from 60 mmeq daily (30 mmeq extended release and 30 mmeq immediate release.) to 30mmeq daily immediate release only. I steadily lost muscle tone, strength, and stamina which at 63 is not easy to recover.  I became less and less functional and eventually,  unable to find a pain management doctor who would restore my stable, carefully planned regimen, I became extremely depressed and suicidal.  Once I was able to obtain different insurance at 65, I was able to begin over again with a caring, compassionate physician who is using a combination of opioid treatment with both extended and immediate release medications in conjunction with facet injections and aspirin to target the inflammation.  I have other medical issues that prevent me from using NSAIDS or antidepressants. And after seeing this physician, 6 months later I am beginning to feel that there is hope that I will once again be able to resume the basic activities and responsibilities that define what having a good quality of life means to me.  I am even able to visit with my granddaughters for more than 30 minutes which had become impossible.

    I lost everything when my opioid regimen was cut. I am a knowledgeable,  responsible and compliant patient who has been in pain management since 2007. I dealt with, survived and corrected the rampant overprescribing Oxycontin period where it was a miracle that I didn't end up an overdose victim.  I willingly welcome my physician's input and recommendations however my opioid use is stable and coupled with reasonable physical activity I have a good life. Your attempt to regulate treatment regimens using a one size fits all mentality without any accommodations for stable,  long term patients with managed pain using opiods in conjunction with appropriate additional targeted therapies is destroying lives needlessly.  Many patients who are older, such as myself,  get the clear message that if we csn deal with the new guidelines we should have the sense to sit or lay in bed and wait to stop breathing.

    If opioids are working and are not being abused,  patients being effectively treated with an opioid based regimen should be allowed to have a life and not suffer needlessly day in and day out,  waiting for their suffering to end.

    What you've done is grouped pain management patients in with people who are suffering from a substance abuse disorder.  You create an environment of refill instability which causes pain patients to demonstrate many behaviors that are difficult to distinguish from drug seeking behavior in an addict.  You have destroyed the hopes and lives of so many. And although the CDC went to great lengths explaining that these guidelines were not to be applied across the board to chronic pain patients who had stable,  effective regimens in place, nowhere in the new guidelines is caution to physicians included for such patients.  No where is it acknowledged that achieving an effective pain management regimen that allows for a reasonably good quality of life takes time and months of collaboration between the patient and the physician and that disruption of such a regimen can and does destroy both physical and psychological well being.

    It appears that once again,  the ability of the physician to develop an individualized, effective pain management regimen has been unforgivably interfered with and ultimately the decisions regarding the most appropriate treatment options are being dictated by governmental agencies and non-clinical medical professionals who have no interaction at all with the patients involved. Their primary concern is not patient wellbeing and improved quality of life,  but adherence to politically and socially acceptable guidelines.

    You have implemented so many reporting requirements that doctors often refuse to consider opioid therapy,  even in patients with long standing regimens,  for fear of accidental document violations in an extremely demanding, fast paced clinical environment.

    I had hoped you would correct the mistakes made with your first set of guidelines.  No I simply pray that my current doctor doesn't retire until after I die.

    • vicki auer vicki auer United States says:

      I think your comments are very well written.  I, like you, have been on pain management for many years.  I am 72 and pain has become a part of life, but so far has been manageable with opioids, and injections and physical therapy when needed.  I mainly deal with nerve damage from a shoulder dislocation 10 years ago, and back pain which extends down my legs.  I have a wonderful pain management doctor who has worked with me for years.  We have tried all types of medications typically for nerve pain and they don’t work for me.  I tried Lyrica for a while which did have a little benefit, but caused quick weight gain, which I felt would be adverse for my back problems, so I stopped it.

      I live alone now since my husband passed away last year.  My pain doctor’s office is on the opposite side of town from where I live, but I don’t want to lose him.  We have developed a mutual trust.  we have a contract and I have no problem giving a urine sample whenever he wants it to see if I am following our agreement.  I worry that I may have to move someday to be closer to family, or worse into assisted care where I won’t have a doctor that understands my situation and takes all of these governmental guidelines as gospel instead of giving best treatment.

      I am very careful and understand peoples concerns about opioid addiction.  My sister died of an overdose.  She had broken her back, had two failed surgeries and in the 90’s had a doctor  that gave her whatever she wanted.  She went through rehab twice. She was not only on opioids, but also anti-depression and anti-anxiety meds.  Unfortunately, she overdosed in 2017.  I hate taking opioids.  I get no high or good feeling, but I do get relief from constant pain and have to deal with the side effect of constipation.

      Your comments are right on and I am hopeful that the people who make the rules and write the recommendations can understand theater one size does not fit all.

    • Pam Mullvain Pam Mullvain United States says:

      I am in a very similar situation and I've often said that I pray, and I do pray, that my current pain management Dr doesn't retire until I die!!!!

    • Dave Seth Dave Seth United States says:

      People who are suffering most are the ones who still suffer. This opioid war (so called) has done ZERO to deter substance abusers but unrepairable damage to chronic pain suffering. Thank God I found Kratom it's been a lifesaver!

    • Harriet Pearson Harriet Pearson United States says:

      You nailed it! I would take this one step further. This coming from a country letting fentanyl flow like water over our boarders is rich. In many cases taking away pain meds from a patient who truly needs them and has demonstrated responsible usage should be left alone. Doctors not properly addressing pain in a timely manor or assuming it's psychosomatic is why people turn to street drugs. There are hundreds dying daily from fentanyl OD's. But, patients with long term diseases causing terminal pain those people they worry about opioid abuse and addiction. Our government and medical profession need to rethink their priorities.

  3. Cheryl Zibbell Cheryl Zibbell United States says:

    I totally agree with everything said and suffering more currently with less pain control despite MRI showing spinal degeneration is severe and worse than prior to initial guidelines that this state calls laws.  The state insurance playing dr is also unacceptable.  I am being punished for suffering with chronic pain.  Almost as bad as being imprisoned for being innocent.  The drug addicts are still there with their street drugs that are stronger than anything I get prescribed for life altering pain.  People are individual and it never works to treat them as a group that they are not even a part of.

  4. Ingrid COULTER Ingrid COULTER United States says:

    As a patient that had breast cancer in 2010 and now dealing with a type of blood cancer I deal with headaches 24 hours a day often 7 days a week, and have tried every migraine medication on the market including giving myself shots and nothing helps in fact everything new I've tried seems to make me sicker than when I started out with just the headaches. The government playing God and saying I only need two Norco pills a day when I'm trying to work an 8 hour day is not working and has not been working for me and causes me to lose many days off a month due to the side effects of these headaches. When the instructions say You're supposed to take two pills and they've got me taking one twice a day it takes the edge off but I still have days when I sit at my computer wearing sunglasses and have all of my blinds d r a w n with no lights on because of the blinding headaches, nauseousness, vomiting and so on. I'm 6 ft tall and one pill twice a day doesn't work for me I'm not petite like Barbie! All I want to do is be able to work and not pray to make it through the day and I'm being treated like three pills a day makes me a junkie or something! I think the government needs to make sure that we don't have doctor Shoppers and all of those kind of things but if something's legitimately helping me to make it through the day, who are they to play God and mess with that? I didn't want cancer, I don't want cancer of my blood, if I had a choice I'd rather not take Norco and not have all the health problems I do, but it's not an option! I for one, hope that my doctor realizes that if I wanted to kill myself I would have done that a long time ago, without my medication I could see that becoming a possibility in some people! I'm just tired of the government playing God and making the doctors so paranoid as well as the pharmacies just to keep people like me employed and able to do my job successfully and not missing a week to 10 days a month because of my severity of my headaches!

  5. Maggi Morgan Maggi Morgan United States says:

    While this shows a slight improvement in those with acute sub-acute and chronic pain it says nothing for those with intractable pain. The fact remains that the original CDC Opioid Guidelines were so flawed in the fact that those 12 authors that wrote it, supposed experts really had no expertise in the area of opioid use to treat pain and had a duty to every living thing that their judgement affected and only fueled the addiction issues in this country and the rise in suicide rates. Though the CDC finally and quietly admitted that their statistics were off by half (I'm sure it's much higher) and that the authors did not differentiate between illegal (heroin) and legally prescribed opiates such as Vicoden, Norco, Morphine, and Dilauded...they also didn't add to their statistics those that died from taking rx opioids mixed wth alcohol or those who failed to take their opioids as directed. Those that did may have done so in order to relieve increasing pain because of the shame in how people in pain have been forced to feel for something we have no control over, while others may have intentionally did so because of the hardships we've faced due to being hurt by injury, illness, or surgical intervention. The CDC is solely responsible for the deaths of people who were forced tapered to fast or cut off and fired by their treating physician. Furthermore people who have successfully taken their benzodiazepines and opioids,  in many cases for decades were forced to choose between treating pain or treating the thoughts associated with severe nonstop pain and the PTSD that many now have due to being treated so horribly by (so called) medical professionals. The CDC had a duty to investigate exactly how their guidelines would affect those that truly needed them and their benzos. It is nothing less than humiliating and degrading to be treated like we are 4th waivers and forced to provide a urinalysis in order to receive another month's supply of pain relief, knowing that false positives are the norm now. In some cases I would venture to even say that those who had a postive UA or a UA that showed zero opiods, (which would mean they were being diverted) was done intentionally and instead of investigating further labs cut off these patients in such a cold-hearted manner then had that put in the electronic medical record so that any future possible treating physicians would see that red flag and refuse to treat anything but the pain. Trying to find a new doctor in this hostile climate is next to impossible as it is but with a red flag it is certain that while they may agree to be your new doctor they will not treat your pain, just yours and those like the others that have had false postive UA's. The new doctor will know all about you before you arrive and from the moment they enter the exam room they will not even give you eye contact so that they can more easily deny you the care you need. Not only do these authors deserve to not work in medical investigation some have gone on to make other career choices to include being paid for expert witnesses in lawsuits earning at least half a million per, Andrew Kolodny should have never been a part of the 2016 guidelines while CEO of a drug rehab as he had personal interest in doing so, getting rich off the backs of those he helped force into withdrawal by having them declared being addicted so to safely detox would need rehab. The money he had raked in should be given to the families whose loved ones died because they are the ones that have been in an uproar that began when their child (adult) wanted to make someone else responsible. Many of the people who have gone on to addiction didn't begin with an rx of their own many were given it by someone else which made them feel better in a way that changed the way they felt in their head. Made them want more, like the heroin addict will say that that first high will have you chasing it into an early grave if not jails, prisons and other instituions. Another fact who has the right to call anyone an addict. Even in Narcotics Anonymous you are not considered an addict until you raise your hand and say Hi my name is _____and I'm an addict. Likewise, I believe that when someone is able to beat their addiction they should be able to say My name is____and I am not an addict. No one has a right to to label someone especially someone with intractable pain. People in pain we can't handle all the hoops we are forced to jump thru to get another month's supply of quality of life which is minimal because of the mme that we require to control pain,  we'd rather die trying to get quality of life than live a life in pure hell. Knowing that there is medication that has been manufactured for the purpose of treating pain but cannot get it, its a fate worse than death and I find it ironic that the makers of opioids like oxycontin needed permission of the federal government to manufacture these opioids then turned around decades later to sue them for what they were permitted to do by law. So when I was profiled for being a drug seeker and denied an MRI which would have showed the horrific injuries but was denied I didn't merit one said er Dr., and nothing for pain for the misdiagnosis I received bruised coccyx plus drug tested by telling me they were checking for internal bleeding not knowing I worked in Healthcare myself, I gave it in hopes of receiving better treatment and though my drug screen came back "nothing worth noting" I was treated like the black plague and it took 6 months and at the order of another specialist to give me the MRI to see I had actually broke my back, ejected the disc between L4 and L5 which caused a vertebral collapse and cervicogenic migraines and a left anterior 2nd rib fracture, well if that makes me a drug seeker, then shame on them at the medical community in Spokane WA and the CDC for creating this huge problem that had affected 124+million people. Oh and let me add that the statistics are constantly changing as our world becomes more populated was that figured in? I doubt it.

  6. Carmen McCombs Carmen McCombs United States says:

    Hole lotta good this will do your first guidelines have already caused laws to be passed and thousands of people cut off n yeah sure for some they're able to find another Dr but for a majority they aren't able due to insurance or lack of available Dr remote areas.   They don't even care No one shall be subjected to torture or to cruel, inhuman or
    degrading treatment or punishment.
    UNIVERSAL DECLARATION OF HUMAN RIGHTS (1948, art. 5)
    INTERNATIONAL COVENANT ON CIVIL AND POLITICAL RIGHTS (1976, art. 7)
    [T]he term “torture“ means any act by which severe pain or
    suffering, whether physical or mental, is intentionally inflicted on a
    person for such purposes as obtaining from him or a third person infor-
    mation or a confession, punishing him for an act he or a third person
    has committed or is suspected of having committed, or intimidating
    or coercing him or a third person, or for any reason based on discrim-
    ination of any kind, when such pain or suffering is inflicted by or at
    the instigation of or with the consent or acquiescence of a public offi-
    cial or other person acting in an official capacity. It does not include
    pain or suffering arising only from, inherent in or incidental to lawful
    sanctions.
    CONVENTION AGAINST TORTURE AND OTHER CRUEL, INHUMAN OR
    DEGRADING TREATMENT OR PUNISHMENT (1984, art. 1, para.1)

  7. Jean Kutzer Jean Kutzer United States says:

    Research has been done by investigative journalists showing the so called opioid crisis to be grossly misinterpreted. The CDC groups heroin and fentanyl od deaths together with prescription od deaths. They also never mention  what else may have been in the blood of an od victim like alcohol, Xanax etc. No mention of new medications that came out like Exstamsil (hope that's spelled right) which has to be taken with food to activate. It can be crushed, sprinkled over food or whatever but won't work without food so extremely difficult to abuse. Doctor shopping was reduced significantly by 2010. And then there is 2012 where an additional event is not mentioned at all. That's the year the DEA expanded the drug war and helped the Cartels increase their profits. Intentional? Doesn't matter as the drug laws themselves had nothing to do with health. The AMA never endorsed drug laws when they originated and in fact were intentionally left out. In 2012 the DEA forced the manufacturers of Oxycontin to reduce production by 25%. This ultimately created a chain reaction. Shortages, price increases and reduced prescriptions, Doctors quitting under too much regulation etc. Patients committing suicide or turning to street drugs like heroin or fentanyl. Shortages of heroin ensued so Cartels began adding fentanyl to the mix. The Chinese cheaply provide the product and why not since the British taught them well about how a Cartel operates. They got Hong Kong back didn't they? No one talks about how they lost it either. The Cartels profits have soared ever since thanks to their new defacto partner the DEA. The CDC has most of this information but reclassifie it under different heading so it's never the same place to be found. They use these same tactics in other areas as well and are quite good at it. Definitions are often redone to suit their needs. Just look at the last two years. As is often the case most problems arise because of government. And when they are turned to in order to fix it why be shocked when they make it worse. The Express News in San Antonio interviewed County Judge Nelson Wolfe in August 2018 about class action lawsuits coming up. Here's a quote; "We have to get in quickly on lawsuits against Big Pharma or risk LOSING OUT on MAKING MORE MONEY than was MADE in the tobacco lawsuits." So there you go in words of babes. Or in this case Statists.

  8. Sharon Lord Sharon Lord United States says:

    I have been in pain management for 10 years. I have DDD, rheumatoid arthritis. Fibromyalga, sciatic back pain, and a pinched nerve. I got gone thru therapy and tried all types of meds. I have had injections and nerve blockers.  It got to the point where all of those stopped working. My doctor told me my last resort was surgery.which is definitely not what I want.
    Finally I was put on an opioid to try. My pain level decreased but was able to start enjoying life more. If my medication was no longer prescribed to me I would probably wind up committing suicide

    People with chronic pain are the only ones tht understand what other people with it go thru. Those of us on opioids for chronic pai definitely don't misuse it for fear
    of it being taken away.

    We have to have it in order to have some quality of life. If it is taken away from those of us with serious chronic pain I believe there would be alot of suicides.

  9. Ernie Gay Ernie Gay United States says:

    I have been on pain medication since 210 when I blew my back out working in mines for 22 years as a mechanic. I was scheduled for a t-lift at L4 L5 S1. Well after having the fusion the Dr in Anchorage Alaska also did nerve damage to my nerves in both legs. The pain has never went away to this day and has gotten worse. Even with a Nero stimulator implant ( due to the battery being dead) and is scheduled for replacement. I have said all of this to say ANTI INFLAMMATORY DRUGS DON'T HELP AT ALL.. THANK YOU FOR LETTING ME SAY THIS

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News Medical.
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