For the first time since 2016, the US Centers for Disease Control and Prevention has updated its guidelines for clinicians and patients on the use of prescription opioids to treat short-term and long-term pain.
The new guidelines from the CDC, published Thursday, include 12 recommendations for clinicians who are prescribing opioids for adults with acute pain lasting less than a month, subacute pain lasting one to three months and chronic pain lasting more than three months.
The update comes as drug overdose deaths have risen dramatically in recent years, although the majority of those deaths are now driven by illicit synthetic opioids, not prescription drugs.
The guidelines shift away from more stringent 2016 guidelines around prescribing that some experts said led to “unintended consequences” for patients with pain. The update includes more focus on treating short-term acute and subacute pain, as well as more emphasis on clinicians and patients already receiving ongoing opioid therapy to work together to assess the risks and benefits of long-term opioid use.
“The science on pain care has advanced over the past six years,” Dr. Debbie Dowell, chief clinical research officer for CDC’s Division of Overdose Prevention, said in a news release Thursday. “During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians. 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 guidelines recommend that clinicians should consider nonopioid therapies for many common types of acute pain, which is pain lasting for less than one month. That guidance is a B recommendation, meaning that it might not apply to all patients and decisions should be made based on the patient’s circumstances. The guidelines also note that “nonopioid therapies are preferred for subacute and chronic pain,” which is paining lasting for more than a month. That guidance is an A recommendation, meaning it typically applies to all patients in that medical situation.
Advice for doctors and patients
The guidelines recommend that when starting opioid therapy for any pain patient – acute, subacute or chronic – “clinicians should prescribe immediate-release opioids instead of extended-release and long-acting” opioids, as evidence has not been found to show that continuous long-acting opioids are more effective or safer than intermittent use of immediate-release opioids
“When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage,” according to the updated guidelines. “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.”
Clinicians also should evaluate the benefits and risks of long-term opioid therapy with subacute or chronic pain patients within one to four weeks of starting the therapy, the guidelines recommend, and for any pain patient, when prescribing initial opioid therapy, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring programs.
Dr. Christopher Jones, acting director of CDC’s National Center for Injury Prevention and Control, said on a call with reporters Thursday that the guidelines now offer guidance to help clinicians and patients weigh the benefits and risks of tapering opioids.
“The guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids,” he said.
“That is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered. And we’ve seen that play out certainly in the research and also from personal stories from patients whose clinicians stopped prescribing to them or abandon them from care or rapidly forced them to get to a much lower dose of opioids and there are very real harms.”
The guidelines also note that “clinicians should offer or arrange treatment with evidence- based medications to treat patients with opioid use disorder.”
‘Expanding the scope’
Opioid prescriptions have steadily declined since reaching a peak in 2012, dropping from more than 80 prescription fills for every 100 people to less than 50 fills for every 100 people in 2019 and 2020, according to CDC. Drug overdose deaths have been rising dramatically in recent years, reaching record levels during the Covid-19 pandemic.
Opioids are still involved in the vast majority of drug overdose deaths, but synthetic opioids – particularly fentanyl – have played an outsized role. Synthetic opioids – excluding methadone – were involved in more than 72,000 overdose deaths in 2021, about two-thirds of all overdose deaths that year and more than triple the number from five years earlier.
Overdose deaths involving natural and semi-synthetic opioids, however, declined about 6% in the same time, dropping below 14,000 deaths in 2021.
“The release of the guidelines today it’s about advancing pain care. We know that at least one in five people in the country have chronic pain. It’s one of the most common reasons why people present to their health care provider. And the goal here is to advance pain function and quality of life for that patient population, while also reducing misuse, diversion, consequences of prescription opioid misuse,” Jones said Thursday.
“But I want to be very clear that actions related to the current state of the overdose crisis, which are very much driven by illicit synthetic opioids like illicitly made fentanyl resurgent methamphetamine, are not the aim of this guideline today,” he said. “I think we can pursue both of those at the same time. But today’s announcement is really about improving the lives of patients living with pain.”
The CDC’s previous 2016 guidelines for prescribing opioids emphasized that non-opioid treatments were preferred methods to manage chronic pain, and opioids should be used only when the benefits outweigh the risks. Those recommendations called on prescribers to limit initial prescriptions to three days or less.
While the 2016 guidelines focused on recommendations for primary care physicians, the updated guidelines now expand the scope to additional clinicians, noting that primary care doctors prescribe about 37% of all opioid prescriptions, and other clinicians account for considerable proportions of prescriptions, such as pain medicine doctors prescribe 8.9% and dentists prescribe 8.6%.
“Pain medicine and physical medicine and rehabilitation clinicians prescribe opioids at the highest rates, followed by orthopedic and family medicine clinicians,” CDC researchers wrote in the updated guidelines. “Thus, expanding the scope to outpatient opioid prescribing can provide evidence-based advice for many additional clinicians, including dentists and other oral health providers, clinicians managing postoperative pain in outpatients, and clinicians providing pain management for patients being discharged from emergency departments.”
The new guidelines also highlight how Black and Brown patients living with pain are less likely than White patients to receive the pain treatments they may need.
“We’ve tried to infuse principles around equity and disparities and pain care, in particular around communities of color throughout the guideline,” Jones said. “Thinking about populations, taking into account cultural language barriers, other aspects of pain care, will be important as we continue to develop those resources.”
The American Pharmacists Association applauded the CDC’s update in a statement on Thursday, calling it a “significant improvement” over the 2016 guidelines.
“In 2016, CDC first released an opioid-prescribing guideline for chronic pain, and while well-intentioned, dosage thresholds and other aspects of the guideline were incorporated into laws, regulations, and policies that resulted in severe, unintended consequences for some patients.
“Most notably, CDC has made clear not just how these guidelines should be used but also how they should not be used, which should go a long way toward curbing the unintended consequences of the past. APhA encourages CDC to collaborate with other stakeholders to address current laws, regulations, and policies that will cause conflict with clinicians’ abilities to effectively implement this guideline and to monitor for unintended consequences of the new guideline.”
A lack of evidence remains
Overall, the CDC’s 2022 guideline for prescribing opioids aims to promote equitable, informed, individualized and safe pain management for patients – but evidence to guide treatments is still lacking, Dowell and other researchers from CDC, the National Center for Injury Prevention and Control, and Oregon Health and Science University, wrote in a perspective paper that published in the New England Journal of Medicine on Thursday.
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“Ideally, new recommendations should result in greater and more equitable access to the full range of evidence-based treatments for pain, more judicious initial use of opioids, and more careful consideration and management of benefits and risks associated with continuing, tapering, or discontinuing opioids in patients who are already receiving them long term,” Dowell and her colleagues wrote in the paper.
“Evidence to guide the best achievable pain management remains limited, and research should address critical remaining gaps, including longterm comparative effectiveness of therapies for pain,” they added. “Patient–clinician communication about benefits and risks associated with opioids remains central to treatment decisions.”