The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain (2022 Clinical Practice Guideline) updates and replaces 2016 CDC Guideline for Prescribing Opioids for Chronic Pain.
The 2022 Clinical Practice Guideline broadens the scope from primary care physicians to include additional clinicians whose practice areas include prescribing opioids in outpatient settings (upon discharge from hospital, emergency departments, and other facilities) for patients 18 years or older.
- Family physicians
- Nurse practitioners
- Physician assistants
- Dental and other oral health clinicians
- Emergency clinicians providing pain management for patients being discharged from emergency departments
- Occupational medicine physicians
- Physical medicine and rehabilitation physicians
- Obstetricians and gynecologists
The 2022 Clinical Practice Guideline refers to and promotes integrated pain management and collaborative working relationships among clinicians, including, for example, behavioral health specialists such as social workers or psychologists, pharmacists, and registered nurses.
Initial and Ongoing Opioid Therapy
The guidance aims to clearly delineate recommendations that apply to patients who are:
- Being considered for initial treatment with prescription opioids, or
- Already receiving opioids as part of their ongoing pain management.
The benefits and the risks of opioid therapy change over time and should be re-evaluated periodically (Recommendations 6 and 7). In the 2022 Clinical Practice Guideline Recommendation 5 outlines situations when clinicians should consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy and that these approaches should be discussed with patients prior to initiating changes. Recommendation 5 also includes revised and expanded guidance on the following key topics to support opioid tapering when indicated:
- Determining whether, when, and how to taper opioids
- Providing advice to patients prior to tapering
- Pain management during tapering
- Behavioral health support during tapering
- Tapering rate
- Management of opioid withdrawal during tapering
- Challenges to tapering
- Continuing high-dosage opioids
Considerations for Opioid Dosages
Opioid dosage guidance was updated regarding:
- Suggestions for the lowest starting dose for opioid-naïve patients.
- Morphine milligram equivalent doses for commonly prescribed opioids.
- The approach to potential dosage increases, emphasizing principles of safe and effective pain treatment that allow for individual circumstances and flexibility in care.
The recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician-patient decision-making.
Guidance on opioid pain medication dosage thresholds was updated in the 2022 Clinical Practice Guideline. Recommendation 4 states that if opioids are continued for subacute or chronic pain, clinicians should:
- Use caution when prescribing opioids at any dosage.
- Carefully evaluate individual benefits and risks when considering increasing dosage.
- Avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.
These recommendations apply specifically to starting opioids or to increasing opioid dosages, and a different set of benefits and risks applies to reducing opioid dosage. Specific considerations to inform clinical decision-making and individualized patient care can be found in the supporting text of the recommendations.
All patients with pain should receive treatment that provides the greatest beneﬁts relative to risks. This includes consideration of nonopioid therapies. The 2022 CDC Clinical Practice Guideline has expanded guidance on nonopioid options for pain such as:
- Topical or oral non-steroidal anti-inﬂammatory drugs (NSAIDs)
- Immobilization and/or exercise