CDC opioid prescribing guidelines - 2022

[deleted131481]

CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 | MMWR

This report describes CDC’s updated clinical practice guideline for prescribing opioids for pain.

www.cdc.gov

Fresh off the press! I did a quick skim through. Seems to pay some closer attention to tapering/risks of stopping abruptly as well as more latitude on prescribing for legacy patients.

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[Ducttape]

summary:

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 category: B; evidence type: 3).

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 (recommendation category: A; evidence type: 2).

Recommendation 3​

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 (recommendation category: A; evidence type: 4).

Recommendation 4​

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 category: A; evidence type: 3).

Recommendation 5​

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 (recommendation category: B; evidence type: 4).

Recommendation 6​

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 (recommendation category: A; evidence type: 4).

Recommendation 7​

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 (recommendation category: A; evidence type: 4).

Recommendation 8​

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 (recommendation category: A; evidence type: 4).

Recommendation 9​

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 (recommendation category: B; evidence type: 4).

Recommendation 10​

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 (recommendation category: B; evidence type: 4).

Recommendation 11​

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 (recommendation category: B; evidence type: 3).

Recommendation 12​

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 (recommendation category: A; evidence type: 1).

 

[Ducttape]

much more benign than the previous recommendations. for example:

• Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day but are exposed to progressive increases in risk as dosage increases. Therefore, before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks. If a decision is made to increase dosage, clinicians should use caution and increase dosage by the smallest practical amount. 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.
• Additional dosage increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits for pain and function relative to risks to patients as dosage increases further. Clinicians should carefully evaluate a decision to further increase dosage on the basis of individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain and function relative to risks with previous dosage increases, other treatments and effectiveness, and patient values and preferences. 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.

so MED >50 is not a hard rule but a suggestion.

• At times, clinicians and patients might not be able to agree on whether or not tapering is necessary. When patients and clinicians are unable to arrive at a consensus on the assessment of benefits and risks, clinicians should acknowledge this discordance, express empathy, and seek to implement treatment changes in a patient-centered manner while avoiding patient abandonment.
• Patient agreement and interest in tapering is likely to be a key component of successful tapers.

the section on tapering states that tapering should be optimized to the patient, that 10% a month may be too fast, and that some patients may require months to years to taper.


why taper?

Consistent with the HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term Opioid Analgesics (219), clinicians should consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy and discuss these approaches with patients before initiating changes when

• the patient requests dosage reduction or discontinuation,
• pain improves and might indicate resolution of an underlying cause,
• opioid therapy has not meaningfully reduced pain or improved function,
• the patient has been treated with opioids for a prolonged period (e.g., years) and the benefit-risk balance is unclear (e.g., decreased positive effects because of tolerance and symptoms such as reduced focus or memory that might be due to opioids),
• the patient is receiving higher opioid dosages without evidence of benefit from the higher dosage,
• the patient experiences side effects that diminish quality of life or impair function,
• evidence of opioid misuse exists,
• the patient experiences an overdose or other serious event (e.g., an event leading to hospitalization or injury) or has warning signs for an impending event (e.g., confusion, sedation, or slurred speech), or
• the patient is receiving medications (e.g., benzodiazepines) or has medical conditions (e.g., sleep apnea, liver disease, kidney disease, or fall risk) that increase risk for adverse outcomes.

and, of note:

Patients who are not taking prescribed opioids (e.g., patients who are diverting all opioids they obtain) do not require tapers.

 

[Agast]

Looks like meat’s oxy’s back on the menu boys!

 

[drusso]

summary:

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 category: B; evidence type: 3).

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 (recommendation category: A; evidence type: 2).

Recommendation 3​

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 (recommendation category: A; evidence type: 4).

Recommendation 4​

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 category: A; evidence type: 3).

Recommendation 5​

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 (recommendation category: B; evidence type: 4).

Recommendation 6​

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 (recommendation category: A; evidence type: 4).

Recommendation 7​

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 (recommendation category: A; evidence type: 4).

Recommendation 8​

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 (recommendation category: A; evidence type: 4).

Recommendation 9​

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 (recommendation category: B; evidence type: 4).

Recommendation 10​

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 (recommendation category: B; evidence type: 4).

Recommendation 11​

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 (recommendation category: B; evidence type: 3).

Recommendation 12​

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 (recommendation category: A; evidence type: 1).

Only one evidence type 1 recommendation. Far weaker sauce than any PRP evidence synthesis.

 

[drusso]

Only one evidence type 1 recommendation. Far weaker sauce than any PRP evidence synthesis.

For context:

 

[DOctorJay]

ok had my first patient reference these updates and say they're ready for me to prescribe them some pain meds now

 

[mid|ine]

Ugh, I'm dreading patients trying to use the new guidelines. I liked the old ones. My Rx patterns won't change.

 

[drusso]

Ugh, I'm dreading patients trying to use the new guidelines. I liked the old ones. My Rx patterns won't change.

Tell them that there is only weak sauce evidence for either set of guidelines! The guidelines don't matter.

 

[Asclepius186]

ok had my first patient reference these updates and say they're ready for me to prescribe them some pain meds now

Your patients are more sophisticated than mine. I would give them mad props for reading CDC guidelines lol

 

[Ferrismonk]

My two takeaways:

"Nonopioid therapies are preferred for subacute and chronic pain"
"Only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks"

Since chronic opioids don't benefit pain or function, I say they aren't indicated.

 

[cowboydoc]

My two takeaways:

"Nonopioid therapies are preferred for subacute and chronic pain"
"Only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks"

Since chronic opioids don't benefit pain or function, I say they aren't indicated.

Pretty sure no patient that reads the guidelines with have those takeaways.

 

[Ducttape]

true.

to which i say "yes, that is my clinical assessment. you are free to see other physicians who may reach a different conclusion. let me give you a list of other clinics and dont let the door hit you on the way out."

 

[drrosenrosen]

Your patients are more sophisticated than mine. I would give them mad props for reading CDC guidelines lol

Correction: They read the headline of a USA Today article that mentioned the guidelines.

 

[Agast]

Correction: They read the headline of a USA Today article that mentioned the guidelines.

They watched 20 seconds of a 43 second TikTok

 

[jwalker12]

"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."

It would be nice if insurance companies read these guidelines and realize interventions are considered "nonpharmacologic" and approve them without a million peer to peers

 

[Multimodal]

true.

to which i say "yes, that is my clinical assessment. you are free to see other physicians who may reach a different conclusion. let me give you a list of other clinics and dont let the door hit you on the way out."

exactly what I do. I tell patients that I do not run a high dose opioid clinic and if thats what they want, they can go see any of the clinics listed on my list of alternative providers. I still get a UDT and bill a 99204 but most of the time, they dont come back. If a patient wants to argue about their dose, theyre at the wrong clinic (another fantastic opportunity to provide and document that I gave a list of alternative providers). I used to argue the merits of this with patients but they dont want to hear rational explanations, in most cases they want to be right and get whatever dose they want.

 

[callmeanesthesia]

exactly what I do. I tell patients that I do not run a high dose opioid clinic and if thats what they want, they can go see any of the clinics listed on my list of alternative providers. I still get a UDT and bill a 99204 but most of the time, they dont come back. If a patient wants to argue about their dose, theyre at the wrong clinic (another fantastic opportunity to provide and document that I gave a list of alternative providers). I used to argue the merits of this with patients but they dont want to hear rational explanations, in most cases they want to be right and get whatever dose they want.

“This isn’t Burger King.”

 

[kstarm]

exactly what I do. I tell patients that I do not run a high dose opioid clinic and if thats what they want, they can go see any of the clinics listed on my list of alternative providers. I still get a UDT and bill a 99204 but most of the time, they dont come back. If a patient wants to argue about their dose, theyre at the wrong clinic (another fantastic opportunity to provide and document that I gave a list of alternative providers). I used to argue the merits of this with patients but they dont want to hear rational explanations, in most cases they want to be right and get whatever dose they want.

I see this a lot. I am curious...who do you refer the patients to? Do you refer to docs that are known to prescribe opioids? In which case it seems a little disingenuous to say "I don't think opioids are appropriate for you but go see Dr. X who will" or do you refer them to docs that feels similarly to you that opioids aren't appropriate in which case why would they want the referral? I use to refer out or give numbers but now I don't give other clinic recommendations. I just say this is my plan if you want to work with me, and if not you are free to seek another opinion with someone else.

 

[Ducttape]

i have all of the local pain clinics listed. i do not give out referrals. this is all on them.

if they ask for a referral, i tell them that doing so is not my recommendation, so you have to call them yourself..

if you do not feel comfortable, then you can suggest they google "pain doctors near me".

 

[geauxg8rs]

true.

to which i say "yes, that is my clinical assessment. you are free to see other physicians who may reach a different conclusion. let me give you a list of other clinics and dont let the door hit you on the way out."

Why bother with a list? Just show them the door

 

[drusso]

i have all of the local pain clinics listed. i do not give out referrals. this is all on them.

if they ask for a referral, i tell them that doing so is not my recommendation, so you have to call them yourself..

if you do not feel comfortable, then you can suggest they google "pain doctors near me".

Why not support your local colleagues, get to know them, know what kind of patients they like, their referral policies, etc. Why leave patients in a lurch?

 

[Ducttape]

what lurch?

if they want meds, i am not the guy for them.

they are all offered multidisciplinary treatment. if they refuse, because they want meds, thats not leaving them in a lurch - that is them seeking what they feel is their right.

fyi i know my local colleagues pretty well. thank you very much for insinuating differently.

 

[GoBeers]

Why not support your local colleagues, get to know them, know what kind of patients they like, their referral policies, etc. Why leave patients in a lurch?

sometimes I'm just hoping that all the other pain docs will preach the same message in minimizing the need for opioids to hopefully drill it into some of these patients' heads that opioids isn't the end all be all. but if they choose to provide opioids, then i guess win win for them.