The US Centers for Disease Control and Prevention (CDC) released updated and expanded clinical practice guidance on prescribing opioids to patients with short- and long-term pain.
The new guidance replaces the CDC Guideline for Prescribing Opioids for Chronic Pain released in 2016, which was interpreted by the health care community as imposing strict opioid dose and duration limits and was misapplied by some organizations, prompting guideline authors to clarify their recommendations in 2019.
"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," said 2022 guideline coauthor and Chief Clinical Research Officer for CDC’s Division of Overdose Prevention, Debbie Dowell, MD, MPH, in an agency press release. "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 2022 recommendations include guidance for managing acute (duration of <1 month), subacute (1-3 months), and chronic (>3 months) pain for primary care and other clinicians. The updated recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care, emphasized guideline authors.
"Patients with pain should receive compassionate, safe, and effective pain care," said coauthor and Acting Director of CDC’s National Center for Injury Prevention and Control, Christopher M. Jones, PharmD, DrPH, in the release. "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."
Published in Morbidity and Mortality Weekly Report, the 2022 guidance addresses 4 key areas: determining whether to initiate opioids for pain; selecting opioids and determining opioid dosages; deciding duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use.
Jones and colleagues state that opioids should not be considered as first-line or routine therapy for subacute or chronic pain and add that nonopioid therapies are often 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 Jones and guideline coauthors in a commentary published in the New England Journal of Medicine.
For chronic pain, the 2022 guideline retains the 2016 principles, including that clinicians should maximize use of nonopioid therapies and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks. When opioids are needed, clinicians should begin at the lowest effective dose, evaluate the benefits and risks before increasing dosage, and avoid raising dosage above levels likely to yield diminishing returns, added authors in the commentary.
"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," authors wrote. "Rather, expected benefits specific to the clinical context should be weighed against risks before therapy is initiated."
The new guideline also offerstips for tapering opioids when warranted, but authors stressed that clinicians should avoid rapid tapering or abrupt discontinuation of opioids.
The CDC noted that the recommendations “should not be used as an inflexible, one-size-fits-all policy or law,” but are instead voluntary and offer flexibility to clinicians and patients.
The 2022 guideline incorporated feedback from approximately 5500 public comments since the new version was first proposed in February, including reactions from individuals who discussed their experiences with pain or opioid addiction and barriers to pain care. An independent federal advisory committee, 4 peer reviewers, and members of the public reviewed the draft version, and the CDC revised it in response to the feedback.
“This clinical practice guideline can help inform those decisions and assist clinicians in meeting the unique needs of each person,” concluded Dowell et al. “CDC will revisit this clinical practice guideline when remaining evidence gaps have sufficiently been addressed and another update is warranted.”
Reference: Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1