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

This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years.It updates the CDC Guideline for Prescribing Opioids for Chronic Pain -United States, 2016 (MMWR Recomm Rep 2016;65[No.RR-1]:1-49) and includes recommendations for managing acute (duration of 3 months) pain.The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care.The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use.CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation.CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers.CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances.Recommendations should not be applied as inflexible standards of care across patient populations.This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.MMWR / November 4, 2022 / Vol.71 / No. 3 US Department of Health and Human Services/Centers for Disease Control and Prevention pain outcomes, psychological distress, overdose, and suicidal ideation and behavior (66-71). RationaleSince release of the 2016 CDC Opioid Prescribing Guideline, new evidence has emerged on the benefits and risks of prescription opioids for both acute and chronic pain, comparisons with nonopioid pain treatments, dosing strategies, opioid dose-dependent effects, risk mitigation strategies, and opioid tapering and discontinuation (7)(8)(9)(10)(11).This evidence includes studies on misapplication of the 2016 CDC Opioid Prescribing Guideline (66), benefits and risks of different tapering strategies and rapid tapering associated with patient harm (68,71-73), challenges in patient access to opioids (6), patient abandonment and abrupt discontinuation of opioids (71), a seminal randomized clinical trial comparing prescription opioids to nonopioid medications on long-term pain outcomes (74), the association of characteristics of initial opioid prescriptions with subsequent likelihood for long-term opioid use (75,76), and the small proportion of opioids used by patients compared with the amount prescribed to them for postoperative pain (77-79).Opioid medications remain a common treatment for pain despite declines in the number of opioid prescriptions after 2012 (58).During 2015-2018, approximately 6% of U.S. adults reported use of one or more prescription opioids during the past 30 days (80), and in 2020, approximately 143 million opioid prescriptions were dispensed from pharmacies in the United States (81).Rates of opioid prescribing continue to vary across states, medical specialties, patient demographics, and pain conditions in ways that cannot be explained by the underlying health status of the population, and often are discordant with the 2016 CDC Opioid Prescribing Guideline recommendations (25,77,(82)(83)(84).The prevalence of prescription opioid misuse and prescription opioid use disorder also has declined in recent years.In 2019, among persons aged ≥12 years in the United States, 9.7 million reported misuse of prescription opioids during the past year (a decrease from 12.5 million in 2015), and 1.4 million met criteria for a past-year prescription opioid use disorder (a decrease from 2.0 million in 2015) (85).However, in 2020, prescription opioids remained the most commonly misused prescription drug in the United States (51).Also in 2020, among those reporting misuse during the past year, 64.6% reported the main reason for their most recent misuse was to “relieve physical pain” compared with 11.3% to “feel good or get high” and 2.3% “because I am hooked or have to have it” (51).Taken together, these factors underscore the need for an updated clinical practice guideline on appropriate opioid prescribing for pain and pain management.MMWR / November 4, 2022 / Vol.71 / No. 3 US Department of Health and Human Services/Centers for Disease Control and Prevention