Frequently Asked Questions

The CDC Guideline for Prescribing Opioids for Chronic Pain and related resources were developed to support you as you provide the best possible healthcare to your patients. See below for a collection of frequently asked questions about the Guideline.

The Guideline provides recommendations to primary care providers about the appropriate prescribing of opioids to improve pain management and patient safety. Recommendations focus on the use of opioids in treating chronic pain (i.e., pain lasting longer than three months or past the time of normal tissue healing) in patients 18 years and older. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective treatment while reducing the number of people who suffer from opioid use disorder or overdose from these drugs. CDC aims to save lives and prevent prescription opioid overdoses by equipping providers with the knowledge, tools, and guidance they need.

For more information: visit the Guideline Overview page.

The U.S. is in the midst of an epidemic of prescription and illicit opioid overdose deaths, which killed more than 47,000 people in 2017 alone. On average, more than 46 Americans die every day from prescription opioid overdoses. The amount of opioids prescribed and sold in the U.S. has increased almost 5 times since 1999, yet there has not been an overall change in the amount of pain that Americans report. While prescription opioids can be an appropriate part of pain management, the new guideline aims to improve the safety of prescribing and reduce the harms associated with opioids, including opioid use disorder and overdose.

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Patients with chronic pain deserve safe and effective pain management. While evidence supports short-term effectiveness of opioids, there is insufficient evidence that opioids effectively treat chronic pain in the long run. Further, there is evidence that nonopioid treatments can be effective with less harm. Evidence of the significant risks of long-term opioid therapy has grown considerably in recent years. Opioid use disorder and overdose are real risks of prescription opioid use—particularly with high doses and long-term use.

In addition to the serious risks of opioid use disorder and overdose, prescription opioids can have a number of side effects, even when taken as directed:

  • Tolerance—meaning you might need to take more of a medication for the same pain relief
  • Physical dependence—meaning you have symptoms of withdrawal when the medication is stopped
  • Increased sensitivity to pain
  • Constipation
  • Nausea, vomiting, and dry mouth
  • Sleepiness and dizziness
  • Confusion
  • Depression
  • Low levels of testosterone that can result in lower sex drive, energy, and strength
  • Itching and sweating

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This guideline is intended for primary care providers who are treating adult patients for chronic pain in outpatient settings. The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

Primary care providers account for nearly half of all dispensed opioid prescriptions and their prescribing rates have increased at high rates compared to other specialties. Primary care providers are concerned about prescription opioid misuse, are worried about opioid use disorder, and have expressed their desire for more training in prescribing opioids.

For more information: visit the Information for Providers page.

Among the 12 recommendations in the Guideline, there are 3 principles that are especially important to improving patient care and safety:

  1. Nonopioid therapy is preferred for chronic pain outside of active cancer, palliative, and end-of-life care.
  2. When opioids are used, the lowest possible effective dosage should be prescribed to reduce risks of opioid use disorder and overdose.
  3. Providers should always exercise caution when prescribing opioids and monitor all patients closely.

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CDC recommends reassessing opioid treatment before increasing dosage to 50 MME or more per day and avoiding or carefully justifying opioid titration to 90 MME or more per day. These dosage amounts for increased caution were determined based on the most recent scientific evidence regarding the association between opioid dosage and overdose risk. This evidence is summarized in the Guideline.

Opioid overdose risk increases in a dose-response manner. Dosages of 50–99 MME/day have been found to increase risk for opioid overdose two-fold to five-fold compared with dosages of 1–19 MME/day, and dosages ≥100 MME/day increase risk of overdose up to nine times the risk at 1–19 MME/day. Among a national sample of Veterans with chronic pain receiving opioid treatment and dying of opioid-related overdose, average prescribed dosage was 98 MME day (compared with an average dosage of 48 MME/day among patients not experiencing fatal overdose), suggesting the need for caution before dosages approach 100 MME daily.

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Patients who are prescribed opioids for acute pain are more likely to use opioids long-term, and a greater amount of early opioid exposure (taking opioids for a longer time or at higher doses) is associated with greater risk for long-term use. Physical dependence on opioids is a physiologic response in patients exposed to opioids for more than a few days. Several previous guidelines on opioid prescribing for acute pain from emergency departments and other settings have recommended prescribing <3 days of opioids in most cases, whereas others have recommended <7 days or <14 days.

The Guideline recommends that if opioids are needed in cases of acute pain (not related to major surgery or trauma, such as acute back pain, sprained ankle), ≤3 days will often be sufficient – unless circumstances clearly warrant additional opioid therapy – and that more than 7 days will rarely be needed. If pain continues longer than expected, providers should re-evaluate the patient to make sure nothing was missed.

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The Guideline encourages providers and patients to consider all treatment options, particularly nonopioid therapies that can be used alone or in combination with opioids. It helps providers assess when it is appropriate to initiate opioid use for the treatment of chronic pain and how to safely maintain or discontinue use in patients who are currently on an opioid treatment plan. Patient safety is our top concern, and CDC encourages providers and patients to carefully consider both the benefits and serious risks of these medications in making decisions about chronic pain management.

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The Guideline is not a regulation, but rather a set of recommendations. The recommendations in the Guideline are voluntary, rather than prescriptive standards. The recommendations are intended to support informed clinical decision making in the context of the provider-patient relationship.

Many providers have not received specific training in pain management. Primary care providers, for example, do not receive extensive academic preparation and training in the nuanced and complex issues of pain management, but must make pain treatment decisions. It is important that patients receive appropriate pain treatment, and that the benefits and risks of treatment options are carefully considered. The Guideline provides guidance to providers on how to do this.

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CDC developed the Guideline with practicality in mind, and created user-friendly tools and materials to make them easy for patients and providers to understand and use. CDC will work with professional associations, insurance groups, federal partners, and others to encourage uptake of the Guideline.

For more information, click through the tabs on the Guideline Resources page.

The Guideline does not restrict providers’ ability to prescribe opioids. The Guideline will help primary care providers offer safer, more effective care for patients with chronic pain and will help reduce opioid use disorder, overdose, and death from these drugs.

  • The Guideline will help primary care providers determine if and when to start opioids for chronic pain, outside active cancer treatment, palliative care, and of end-of-life care.
  • It will give providers guidance about medication selection, dose, and duration, and when and how to reassess progress, and discontinue medication if needed.
  • And, it will help providers and patients—together—assess the benefits and risks of opioid use and address potential harms.

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It is important for CDC to continue to research opioid use disorder and overdose and help inform and improve providers’ ability to offer safer, more effective care based on the best available science.  As part of that process, CDC will evaluate the uptake, use, and public health impact of the Guideline and will monitor and assess provider and patient response to the Guideline.

For more information, visit the Data Overview page.

The Guideline is based on the evidence that is currently available. We don’t know whether or not opioids provide effective pain relief over the long term. At the same time, we know now that opioid use disorder and overdose are real risks of prescription opioid use—particularly with high doses and long-term use.

Clinical guidelines are always based on best available evidence, including low quality evidence. When evidence is low quality, it does not necessarily mean there is not enough evidence to make a recommendation. It means that not enough randomized control trials were conducted to describe the evidence as “high quality.” We need more rigorous studies on effective treatments for pain.

CDC agrees that we need more research on effective pain treatments and is dedicated to working with partners to improve the evidence base, and will refine our recommendations as better evidence becomes available.

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CDC made many revisions to the Guideline based on public comments and input from the NCIPC Board of Scientific Counselors. Examples of these revisions include:

  • Placing greater emphasis on patient-centered principles, the relationship between the provider and patient, and team-based care.
  • Providing greater flexibility for dosage amounts, specifying that providers should avoid or carefully justify a decision to titrate dosage to > 90 MME.
  • Providing greater flexibility for duration of opioids for acute pain, indicating that three days or less will often be sufficient; more than seven days will rarely be needed.
  • Including more information about specific translation materials that will be available and where readers may access them, and complementary efforts that will be conducted with partners to support guideline implementation and improve the evidence base.

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In the Opioid Prescribing Guideline, CDC indicated an intent to evaluate and assess the Guideline as new evidence became available, and to determine when research gaps would prompt an update. CDC is funding the Agency for Healthcare Research & Quality (AHRQ)external icon to conduct systematic reviews of the scientific evidence that has been published since the Guideline was released in March 2016.

Results of these reviews will help CDC determine whether evidence gaps have been addressed and if the Opioid Prescribing Guideline should be updated or expanded. If a Guideline update or expansion occurs, the development process would include results from the ongoing systematic reviews and an additional public comment period through the Federal Register once an update or expansion is drafted. Given these projected activities, a Guideline update or expansion would potentially release in late 2021.

For information on the AHRQ systematic reviews, visit: https://effectivehealthcare.ahrq.gov/external icon

CDC Guideline for Prescribing Opioids for Chronic Pain