CDC Revises Opioid Prescribing Guidelines
The CDC’s new opioid prescription guidance provides more flexibility for patients’ pain treatment.
By Linda Rath | Nov. 9, 2022
The Centers for Disease Control and Prevention (CDC) has updated recommendations for opioid use, clarifying or reversing some aspects of guidance it issued in 2016 amid surging rates of opioid misuse and abuse. Widespread use of the 2016 guidelines, which suggested limits on drug dose and duration, helped drive down the rates at which opioids were being prescribed to 15-year lows in some states.
But patient advocates and pain experts argue that the 2016 guidelines also caused unintended harm. While limiting new prescriptions, they penalized patients who were taking opioids to control chronic pain by abruptly reducing their dose or cutting them off completely. Studies show that the sudden cessation of opioid use, especially long-term opioid use, leads to increased pain, psychological distress, and in some cases use of illicit drugs or suicide, the report says.
More Leeway for Providers
In a commentary published in The New England Journal of Medicine (NEJM), CDC officials noted that the original guidelines called on prescribers to voluntarily reduce opioid dispensing. They were never intended to become strict policies or laws. To avoid those problems, the revised guidelines — which are also voluntary — don’t include dosing limits for chronic pain, although they still recommend the lowest dose for the shortest time. The new guidance gives providers more leeway to calibrate dosing and timeframes to meet the needs of individual patients. But the general message is to steer clear of opioids for chronic pain in the first place, and instead to try non-opioid treatments, which are more effective for pain in many cases. Opioid overdose deaths, including those from prescription medications, remain high, although far more are attributable to nonprescription opioids.
Still Not the First Choice for Pain
Although the proscriptive tone of the CDC’s original guidelines has changed, many recommendations remain the same or have been strengthened. They include:
Opioids are associated with only small improvements in pain and function over the short-term and there is limited evidence of long-term effectiveness.
Opioids shouldn’t be prescribed for many common pain conditions, including minor pain from dental or other surgeries and back, neck and musculoskeletal pain like osteoarthritis. Instead, topical medications, heat and cold therapy and other nondrug therapies such as rest, immobilization and exercise, including physical therapy, yoga, tai chi and qigong and acupuncture, usually work better and don’t cause harm or dependence. And unlike pain pills, the benefits often continue after treatment stops.
Nondrug and non-opioid treatments are also recommended over opioids and other drugs for chronic pain. Drug-free options include exercise and exercise therapy, weight loss if needed, cognitive behavioral therapy, yoga, tai chi and qigong, mindfulness meditation and massage. These techniques for relieving pain and restoring function have been proven to be effective in many cases and lack of side effects.
Opioids still have a role in palliative and end-of-life care or severe pain from cancer or traumatic injury, such as burns and crushed bones.
Doctors should prescribe immediate-release instead of extended release or long-acting opioids.
Dosages must be tapered slowly and carefully — about a 10% reduction a month.
Doctors and patients should have clear discussions about the goals of treatment, which may be to manage pain rather than completely eliminate it, which may not be feasible.
A Path Forward
Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control, said the agency would work with clinical organizations and patient advocates to spread the word about the updates. But critics say the lingering effects of the 2016 guidelines may be hard to undo. The Committee for Quality Assurance, Medicare and Medicaid and even law enforcement use the 2016 guidelines to set policy and investigate drug crimes.
Most important is the need for increased access to nondrug pain therapies, especially for people who live in rural areas or are under- or uninsured. Pain patients will only be harmed if opioid prescriptions decline but no alternatives exist to replace them — a problem made clear by the misapplication of the 2016 guidelines. As the authors of The NEJM commentary wrote:
“Ideally, new recommendations should result in greater and more equitable access to the full range of evidence-based treatments for pain, more judicious initial use of opioids and more careful consideration and management of the benefits and risks associated with continuing, tapering or discontinuing opioids in patients who are already receiving them.”