Updated CDC guidelines for prescribing opioids

On November 4, 2022, the United States Centers for Disease Control and Prevention (CDC) updated their clinical practice guidelines for opioid prescription in pain management.

CDC Clinical Practice Guideline for prescribing opioids for pain – United States, 2022. Centers for Disease Control and Prevention. Image Credit: Victor Moussa / Shutterstock.com

The importance of pain management

Pain is one of the four cardinal signs of inflammation, in addition to inflammation, swelling, and loss of function. Pain remains one of the most common complaints for adults seeking medical care in the U.S.

Pain can be classified as acute, sub-acute, or chronic pain. Whereas acute pain is present for less than one month, sub-acute and chronic pain typically have durations for one to three months and more than three months, respectively.

Pain, particularly chronic pain, significantly affects an individual’s quality of life, as well as their physical and emotional health. In fact, between 2003 and 2014, about 9% of suicides had a history of chronic pain; however, this is likely an underestimate.

Taken together, the wide range of adverse effects associated with chronic pain emphasize the importance of the adequate prevention, assessment, and treatment of pain. Furthermore, pain management should be a holistic process that considers the possible reversible causes of the patient’s pain, as well as both pharmacologic and nonpharmacologic treatment options.

The risks of opioids

Opioids are common pharmacological agents that are used to manage pain; however, the long-term use of these agents increases the risk of overdose and misuse. Notably, both immediate- and extended-release opioids have been associated with an increased risk of addiction, abuse, misuse, overdose, and death.

Between 1999 and 2010, the rate of opioid prescriptions within the U.S. increased by four-fold, which subsequently led to a significant rise in opioid use disorders and overdose deaths involving prescription opioids. In addition to a greater overall volume of opioids prescribed during this time, opioids were also prescribed at higher doses and for longer durations in patients, despite the lack of evidence supporting the long-term effectiveness of opioids in the management of chronic pain.

Updated opioid prescription guidelines

In an effort to reduce the adverse effects associated with opioid use, as well as promote the appropriate prescription of these highly addictive drugs, the U.S. CDC Guideline for Prescribing Opioids for Chronic Pain was originally published in 2016. On November 4, 2022, the CDC updated these guidelines to better help clinicians provide informed and personalized pain care to patients.

The priority for managing acute pain is using non-opioid therapies. However, opioid therapy should be considered if the benefits outweigh the risks. Thus, it is imperative that clinicians inform their patients about the benefits and potential risks associated with opioids before initiating treatment.

If the patient is suffering from sub-acute and chronic pain, non-opioid therapies are preferred. Although the use of non-opioid therapies is a priority, prescribing opioids may be considered if the expected benefits outweigh the potential risks.

Immediate-release opioids are preferred over extended-release and long-acting opioids to treat any type of pain.

In patients who have not previously been prescribed an opioid, clinicians should start with the lowest dose that will effectively manage their pain. In patients suffering from chronic or sub-acute pain, the opioid dosage must be carefully selected. 

If the clinician decides to increase the opioid dose for their patients, the individualized risks and benefits should be evaluated and appropriate doses should be prescribed, such that the benefits outweigh the risks.

In cases with acute pain warranting opioid use, only the quantity of opioids necessary for the expected pain duration must be prescribed.

If the clinician prescribing opioids for chronic or sub-acute pain has increased the dose, the risks and benefits should be evaluated within one-to-four weeks. Even after this reassessment point, the risks and benefits must be regularly evaluated and discussed with patients receiving opioid therapy.

Clinicians should assess the side effects of opioid use before and periodically after commencing opioid therapy, as well as periodically discuss the risks of opioid therapy with their patients. Any strategy to reduce the risks of opioid use, including the use of naloxone, must also be discussed.

Before prescribing opioids for any type of pain, clinicians should enquire in detail about the patient’s medical and drug history, past substance abuse, history of overdose, and current use of another central nervous system (CNS) depressant.

Clinicians should remain cautious while prescribing opioids to patients on CNS depressants like benzodiazepines. When concurrent use is indicated, the clinician must evaluate the associated risks against the proposed benefits.

When prescribing opioids for chronic or sub-acute pain, the risks and benefits of toxicology testing should be considered to assess the prescribed opioid dose when used along with other non-prescribed or prescribed controlled substances.

Treatment planning must incorporate evidence-based medications for treating patients suffering from opioid use disorder. Non-pharmacological detoxification of opioid use disorder is not recommended, as it increases the risk of overdose, drug relapse, and overdose-associated fatalities.

Conclusions

The updated CDC guidelines offer effective and safe pain management with apt therapeutic strategy discussions with patients. Thus, these guidelines will aid in the customization of pain management strategies to ultimately improve the quality of life of patients suffering from any type of pain.