When to and Not to Prescribe Opioids : CDC Guidelines at Glance

The CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022 Clinical Practice Guideline) is a clinical tool to help clinicians and patients work together to make informed, patient-centered decisions about pain care.

It includes 12 recommendations for clinicians providing pain care for outpatients aged 18 years or older with acute pain (duration less than 1 month), subacute pain (duration of 1-3 months), or chronic pain (duration of more than 3 months). The summary of the detailed recommendations is mentioned below for ease of reference.

Specifically, they are intended to help clinicians:

• Improve communication with patients about the benefits and risks of pain treatments, including opioid therapy for pain.
• Improve the safety and effectiveness of pain treatment.
• Mitigate pain.
• Improve function and quality of life for patients with pain.
• Reduce the risks associated with opioid pain therapy (including opioid use disorder, overdose, and death)

The 12 recommendations are grouped into four areas of consideration:

Determining whether or not to initiate opioids for pain:

Recommendation 1: Nonopioid therapies are at least as effective as opioids for many common types of acute pain.

• 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 to the patient.
• Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

Recommendation 2: Nonopioid therapies are preferred for subacute and chronic pain.

• 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 to the patient.
• Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Determining Whether or Not to Initiate Opioids for Pain

Recommendation 3 Immediate release opioids are preferred over extended release.

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribeimmediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.

Immediate-release opioids: faster acting medication with a shorter duration of pain-relieving action. Examples include morphine, oxycodone, or hydrocodone.

Extended-release and long-acting opioids: slower acting medication with a longer duration of pain-relieving action. Examples include methadone, transdermal fentanyl, or extended-release versions of opioids such as oxycodone, hydromorphone, hydrocodone, and morphine.

Recommendation 4 Use the lowest effective dose possible.

When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.

If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.

Recommendation 5 Assess the risk vs benefit ratio.

For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage.

• 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.