CDC Releases Highly Anticipated Draft Guidance for Opioid Prescribing 
  • This draft guidance is intended for acute pain, subacute pain, and chronic pain in adults.
  • CDC consistently encourages clinicians to reevaluate the harms and benefits of opioid use during each stage of opioid pain treatment.
  • Comments on the proposed guidance are due April 11, with final guidance expected to be published in late 2022. 
Yesterday, the Centers for Disease Control and Prevention (CDC) released the long-anticipated notice of its draft 2022 Clinical Practice Guideline for Prescribing Opioids. The draft guidance updates the CDC’s 2016 guidance and is intended for clinicians providing outpatient pain care for patients 18 years or older with acute pain, subacute pain, or chronic pain. The 2022 draft guidance includes a detailed summary of findings that informed the CDC’s recommendations. Specifically, the clinical practice guideline addresses: (1) determination process of initiating opioid treatment; (2) opioid selection and dosage; (3) treatment duration and follow-up; and (4) assessing harms of opioid use. CDC notes that final guidance will not applicable to pain stemming from sickle cell disease, cancer, palliative care, or end-of-life care.
  • Background. CDC provides guidance to clinicians in the realm of pain care, primarily through the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain. In that guidance document, CDC noted that it would update guidance accordingly as new evidence and research is developed. Since 2016, the CDC has reviewed noninvasive, nonpharmacological, and nonopioid treatments. The updated 2022 guidance is intended to reflect this research.
These clinical practice guidelines are intended to function as a tool to improve patient-provider communication and are not a law or regulation. In developing the guidelines, CDC collaborated closely with the Opioid Working Group (OWG) and the Board of Scientific Counselors, National Center for Injury Prevention and Control (BSC/ NCIPC). Notably, this updated guidance no longer recommends that doctors “avoid increasing dosage” to 90 morphine milligram equivalents (MME). The new guidance also removed language that suggests limits for acute pain prescriptions.
The CDC’s twelve opioid prescribing recommendations are discussed below:

Determination Process of Initiating Opioid Treatment
  • Clinicians should consider the costs and benefits of prescribing opioids to the patient. CDC notes that nonopioid therapies are effective for many common types of acute pain.
  • Before initiating opioid treatment, clinicians should discuss known risks and “realistic benefits” of opioid treatment and work to establish goals for pain and function. Additionally, this conversation should include discussion of how to discontinue opioid treatment if goals are not met.
Opioid Selection and Dosage
  • When starting opioid therapy, prescribers should use immediate-release opioids instead of extended-release (ER) or long-acting (LA) opioids.
  • For “opioid-naïve” patients, clinicians should prescribe the lowest dose for acute, subacute, or chronic pain. If opioids are continued, CDC urges clinicians to avoid dosage increases above levels that are likely to yield greater risks and outweigh benefits.
  • For patients already receiving higher doses, CDC suggests that clinicians carefully weigh risks when reducing or continuing opioid treatment. If the risks outweigh the benefits of continued use, prescribers should utilize other therapies and work with patients to gradually taper or lower doses. Unless there are indications of a life-threatening situation, CDC recommends that opioid therapy not be discontinued abruptly.
Treatment Duration and Follow-Up
  • In cases in which opioids are deemed necessary for acute pain, clinicians should only prescribe a quantity needed for the expected duration of pain severe enough to require opioids.
  • Within one-to-four weeks of staring opioid therapy, clinicians should evaluate benefits and risks in their patients. These evaluations should occur every three months for which the patient is utilizing opioid therapy.
Assessing Harms of Opioid Use
  • Preceding and during opioid treatment, clinicians should evaluate risk of opioid-related harm. CDC explains that this effort should include mitigation strategies, such as offering naloxone when factors increasing overdose risk are present.
  • Clinicians should periodically review the patient’s history of controlled substance prescriptions via state prescription drug monitoring program (PDMP) data. Clinicians should then determine whether any interactions or dosages put the patient at risk of overdose.
  • Additionally, CDC recommends that clinicians consider toxicology testing for prescribed and non-prescribed controlled substances.
  • Specifically, prescribers should use “extreme caution” when prescribing opioids for a patient taking benzodiazepines concurrently and instead consider other central nervous system depressants.
  • Clinicians should offer to coordinate or arrange medication treatment for patients with opioid use disorder (OUD).

What’s Next? Comments on the draft guidance will be open through April 11, 2022. By late 2022, CDC aims to publish final guidance.