CDC 2022 Opioid Guidelines for the United States

The CDC Clinical Practice Guidelines for Prescribing Opioids for Pain is a framework designed to help health care providers in the United States offer safe and effective pain treatment. This compilation of guidelines is applicable to acute, subacute, and chronic pain, with the exceptions of pain management related to cancer, sickle cell disease, palliative care, and end-of-life care. Additionally, the management of opioid use disorder is included.

2022 recommendation areas

Twelve recommendations are grouped into four areas, which include the following:

1. Determining whether to initiate opioid treatment
2. Selecting the appropriate opioid type and dosage
3. Deciding the duration of the initial opioid prescription and conducting follow-up
4. Assessing risks and addressing potential harms of opioid use

Categories

Each recommendation is also categorized into A or B.

• Category A recommendations indicate that most patients should receive the recommended course of action and that advantages have been determined to greatly outweigh disadvantages.
• Category B recommendations indicate that different courses of action may be appropriate for different patients and situations. This category also includes more balanced advantages and disadvantages.

Area 1: Determining whether to initiate opioid treatment for pain

Recommendation 1: Nonopioid therapies are at least as effective as opioids for many common types of acute pain (recommendation category: B). 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.

Recommendation 2: Non-opioid therapies are preferred for subacute and chronic pain (recommendation category: A). Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient, and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks.

Area 2: Selecting the appropriate opioid type and dosage

Recommendation 3: 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 (recommendation category: A).

Recommendation 4: When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage (recommendation category: A). If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, carefully evaluate individual benefits and risks when considering increasing dosage, and avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks.

Recommendation 5: For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks, and exercise care when changing opioid dosage (recommendation category: B). 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 problem, such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly. Additionally, clinicians should not rapidly reduce current opioid dosages.

Area 3: Deciding the duration of the initial opioid prescription and conducting follow-up

Recommendation 6: 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 (recommendation category: A).

Recommendation 7: Clinicians should evaluate benefits and risks with patients within one to four weeks of starting opioid therapy for subacute or chronic pain, or of dosage escalation (recommendation category: A). Clinicians should regularly reevaluate benefits and risks of continued opioid therapy.

Area 4: Assessing risks and addressing potential harms of opioid use

Recommendation 8: Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients (recommendation category: A). Clinicians should work with patients to incorporate management plan strategies to mitigate risk, including offering naloxone.

Recommendation 9: 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 (recommendation category: B).

Recommendation 10: 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 non-prescribed controlled substances (recommendation category: B).

Recommendation 11: 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 (recommendation category: B).

Recommendation 12: Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder (recommendation category: A). 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.

Guiding principles

The five guiding principles that should broadly inform how the recommendations are applied, especially with regard to patient care and safety, include the following:

1. Acute, subacute, and chronic pain should be appropriately assessed and treated, whether opioids are part of that treatment.
2. Recommendations are voluntary and do not replace individualized, person-centered care. Meeting individual needs is a priority.
3. Physical health, behavioral health, long-term services and support, and expected health outcomes/well-being of each individual are all important to pain management. Taking a multidisciplinary approach to treatment is essential.
4. This clinical practice guideline should not be misapplied beyond its intended use or in a way that could cause unintended harm.
5. It is essential to ensure clear communication that is accessible to all individuals regardless of disability or language barriers so that they may have complete and fair access to pain management, both pharmacologic and otherwise.