2022 Opioid Prescribing Guideline Update Open for Public Comment, says CDC

The Centers for Disease Controls and Prevention (CDC) released a draft update of its 2022 Clinical Practice Guidelines for Prescribing Opioids for pain management — and is asking for public comment before moving forward.

The update follows by 6 years the controversial guidance released by the CDC in 2016 which although intended to help quell rampant opioid abuse in the US, had a swift and significant chilling effect on opioid prescribing leaving health care professionals leery of providing the drugs for pain of almost any severity and some patients with chronic pain cut off from prescriptions they may have taken for years. Authors of the 2016 guidance have maintained that the recommendations were misapplied and even wrongly used in some states by medical boards to sanction clinicians who exceeded what were interpreted as opioid prescribing ceilings.

Clinical judgement should prevail

CDC states that the recommendations are voluntary. They are intended as flexible standards of care and not menat to replace clinical judgment or individualized, patient-centered care. The draft guidance still advises clinicians to limit new opioid prescribing, eg, for acute injuries, and to consider alternative therapies first, saying “opioids should not be considered first-line or routine therapy for subacute or chronic pain.” The authors state that non-opioid medications and interventions like exercise and physical should be prioritized.

But unlike the original guidance, this version does not include hard cutoffs for opioid dosage or length of prescriptions and has removed recommendations that clinicians, for example, “avoid increasing dosage” to 90 morphine milligram equivalents or more per day, or, if it is necessary, to “carefully justify” the decision.

The draft guidance also emphasizes that while tapering or stopping opioids altogether may be appropriate in situations where risks of continued treatment outweigh the benefits, abrupt discontinuation is never recommended; the draft provides a section on “whether, when, and how to taper opioids.”

The guidance, says the CDC, should be a tool to improve patient-provider communication and to ensure patient access to effective pain management while also reducing the risks associated with opioid medications, including opioid misuse and overdose.

The authors reiterate throughout the guideline that the recommendations should not be interpreted or “applied as inflexible standards of care,” but used as a guide to support clinical decision making and individualize patient care.

“We want to hear many voices from the public, including people living with pain and the health care providers who help their patients manage pain,” said Christopher M. Jones, PharmD, DrPH, MPH, acting director for the National Center for Injury Prevention and Control in a CDC statement.

“The ultimate goal of this clinical practice guideline is to help people set and achieve their personal goals to reduce their pain and improve their function and quality of life. Getting feedback from the public is essential to achieving this goal.”

The recommendations apply to clinicians who treat 3 categories of patients: adults with acute pain lasting less than one month; "subacute" pain for one to three months; and chronic pain for three months or longer. Like the original guideline, the recommendations do not apply to sickle cell disease, cancer, palliative, or end-of-life care.

The recommendations are now open on the Federal Register and CDC is accepting comments on the draft through April 11. A finalized update is expected this year.