Guideline Recommendations and Guiding Principles
2022 Clinical Practice Guideline Recommendations
The 12 recommendations are grouped into four areas of consideration.
- Determining whether or not to initiate opioids for pain(Recommendations 1, 2)
- Deciding duration of initial opioid prescription and conducting follow-up(Recommendations 6, 7)
- Selecting opioids and determining opioid dosages(Recommendations 3, 4, 5)
- Assessing risk and addressing potential harms of opioid use(Recommendations 8, 9, 10, 11, 12)
Recommendations are based on a systematic review of the scientific evidence, while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from a federally chartered advisory committee; federal partners; the public including patients, caregivers, and clinicians; and peer reviewers with scientific and clinical expertise.
The recommendations do not apply to pain management related to sickle cell disease, cancer-related pain treatment, palliative care, or end-of-life care.
These five guiding principles should broadly inform the implementation of the 2022 Clinical Practice Guideline recommendations.
- Acute, subacute, and chronic pain needs to be appropriately assessed and treated independent of whether opioids are part of a treatment regimen.
- Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount.
- A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes1 and well-being of each person is critical.
- Special attention should be given to avoid misapplying this clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended and potentially harmful consequences for patients.
- Clinicians, practices, health systems, and payers should vigilantly attend to health inequities; provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities; and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons.
1The terminology “expected health outcomes” refers to what is expected to happen based on an individual’s health/medical conditions.
Nonopioid therapies include:
- Nonopioid medications such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and selected antidepressants and anticonvulsants
- Physical treatments (e.g., heat therapy, acupressure, spinal manipulation, remote electrical neuromodulation, massage, exercise therapy, weight loss)
- Behavioral treatment (e.g., cognitive behavior therapy, mindfulness-based stress reduction)
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.
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.
The appropriate selection of opioids and dosage are important factors when opioid therapy is prescribed as part of a patient’s pain management plan. Recommendations 3-5 address opioid selection and dosage.
When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-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.
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.
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.
Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.
Recommendations 6 and 7 address the duration of opioid therapy and routine patient follow-up.
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 should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients.
Assessing risk and addressing potential harms of opioid use are addressed by recommendations 8, 9, 10, 11, 12.
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients.
Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.
- Ask patients about their drug and alcohol use and use validated tools or consult with behavioral specialists to screen for and assess mental health and substance use disorders.
- Use PDMP data and toxicology screening as appropriate to assess for concurrent controlled substance use that might place patients at higher risk for opioid use disorder and overdose.
When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or combinations that put the patient at high risk for overdose.
When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.
Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.
FDA-approved medications indicated for the treatment of opioid use disorder include buprenorphine, methadone, and naltrexone. Information about qualifications and the process to prescribe buprenorphine are available from the Substance Abuse and Mental Health Services Administration.
Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder.
Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.