For the first time since 2016, the US Centers for Disease Control and Prevention has updated its guidelines for clinicians and patients on the use of prescription opioids to treat short-term and long-term pain.
The new guidelines from the CDC, published Thursday, include 12 recommendations for clinicians who are prescribing opioids for adults with acute pain lasting less than a month, subacute pain lasting one to three months and chronic pain lasting more than three months.
The update comes as drug overdose deaths have risen dramatically in recent years, although the majority of those deaths are now driven by illicit synthetic opioids, not prescription drugs.
The guidelines shift away from more stringent 2016 guidelines around prescribing that some experts said led to “unintended consequences” for patients with pain. The update includes more focus on treating short-term acute and subacute pain, as well as more emphasis on clinicians and patients already receiving ongoing opioid therapy to work together to assess the risks and benefits of long-term opioid use.
“The science on pain care has advanced over the past six years,” Dr. Debbie Dowell, chief clinical research officer for CDC’s Division of Overdose Prevention, said in a news release Thursday. “During this time, CDC has also learned more from people living with pain, their caregivers, and their clinicians. We’ve been able to improve and expand our recommendations by incorporating new data with a better understanding of people’s lived experiences and the challenges they face when managing pain and pain care.”
The guidelines recommend that clinicians should consider nonopioid therapies for many common types of acute pain, which is pain lasting for less than one month. That guidance is a B recommendation, meaning that it might not apply to all patients and decisions should be made based on the patient’s circumstances. The guidelines also note that “nonopioid therapies are preferred for subacute and chronic pain,” which is paining lasting for more than a month. That guidance is an A recommendation, meaning it typically applies to all patients in that medical situation.
Advice for doctors and patients
The guidelines recommend that when starting opioid therapy for any pain patient – acute, subacute or chronic – “clinicians should prescribe immediate-release opioids instead of extended-release and long-acting” opioids, as evidence has not been found to show that continuous long-acting opioids are more effective or safer than intermittent use of immediate-release opioids
“When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage,” according to the updated guidelines. “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.”
Clinicians also should evaluate the benefits and risks of long-term opioid therapy with subacute or chronic pain patients within one to four weeks of starting the therapy, the guidelines recommend, and for any pain patient, when prescribing initial opioid therapy, clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring programs.
Dr. Christopher Jones, acting director of CDC’s National Center for Injury Prevention and Control, said on a call with reporters Thursday that the guidelines now offer guidance to help clinicians and patients weigh the benefits and risks of tapering opioids.
“The guideline explicitly advises against abrupt discontinuation or rapid dose reductions of opioids,” he said.
“That is based on lessons learned over the last several years as well as new science about how we approach tapering and the real harms that can result when patients are abruptly discontinued or rapidly tapered. And we’ve seen that play out certainly in the research and also from personal stories from patients whose clinicians stopped prescribing to them or abandon them from care or rapidly forced them to get to a much lower dose of opioids and there are very real harms.”
The guidelines also note that “clinicians should offer or arrange treatment with evidence- based medications to treat patients with opioid use disorder.”
‘Expanding the scope’
Opioid prescriptions have steadily declined since reaching a peak in 2012, dropping from more than 80 prescription fills for every 100 people to less than 50 fills for every 100 people in 2019 and 2020, according to CDC. Drug overdose deaths have been rising dramatically in recent years, reaching record levels during the Covid-19 pandemic.