Six Years Later - How the 2022 CDC Clinical Practice Guidelines for Prescribing Opioids for Pain Compare to the 2016 Guidelines

Six Years Later - How the 2022 CDC Clinical Practice Guidelines for Prescribing Opioids for Pain Compare to the 2016 Guidelines
Kendra Buettner, PharmD
Essentia Health

Background: In 2016, the Centers for Disease Control and Prevention (CDC) released its first set of guidelines for opioid prescribing in the management of outpatient adults with chronic pain. These guidelines excluded treatment recommendations for pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care. In 2022, the CDC updated the guidelines using new evidence to address the risks and benefits of prescription opioids and expanded them to cover acute, subacute, and chronic pain.

Evidence: The 2016 guidelines had 12 recommendations for prescribing opioids. These recommendations were grouped into three categories that included when to initiate or continue opioids; opioid selection, including dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use. The 2022 guidelines still include the original 12 recommendations; however, they have been adjusted to reflect emerging evidence and now have four categories. The four categories are as follows: determining whether to initiate opioids for pain, selecting and determining opioid dosages, deciding duration of initial opioid prescription, and conducting follow-up and assessing risk and addressing potential harms of opioid use.

To start, the 2022 recommendations address the use of opioids for chronic, subacute, and acute pain whereas the 2016 recommendations were mainly focused on chronic pain management. Recall that the recommendation categories were developed on the basis of evidence type, cost, preferences, and values while balancing desirable and undesirable effects. Recommendation category A applies to all persons, and most should receive the course of action recommended whereas category B recommendations need individual decision making as choices will differ in appropriateness based on the patient. Initial changes from the 2016 guidelines include four recommendations being decreased from category A recommendation to category B recommendation. All the 2016 recommendations were labeled category A, aside from Recommendation 10, which addressed clinicians using urine drug testing before starting opioid therapy.

Taking a closer look into the 2022 guidelines, the first recommendation focuses on acute pain and how clinicians should use nonpharmacologic and nonopioid pharmacologic therapies initially for specific conditions. Previously, initiation of opioids for acute pain was not addressed. The 2022 recommendations still emphasize discussing expected benefits and risks of opioid therapy when used for both acute and chronic pain and include a statement for clinicians to consider how opioid therapy would be stopped should the benefits not outweigh risks. As for initiation of opioid therapy, the guidelines held steady with the recommendation to prescribe immediate-release opioids over extended-release or long-acting opioids when starting opioid therapy for chronic, acute, or subacute pain. Part of this recommendation is due to a fair-quality study that demonstrated a higher risk for overdose when patients were treated with extended-release or long acting (ER/LA) opioids rather than immediate release opioids. Additionally, use of ER/LA opioids have not been shown to be more effective or safer than intermittent use of immediate-release opioids. When it comes to dosage of opioids for pain, the 2022 recommendations reflect the desire to be more flexible. Previously, the recommendation had been to reassess risk versus benefit when increasing to ≥50 morphine milligram equivalents (MME)/day and to avoid dosages above ≥90 MME/day. However, the updated guidelines state that caution should be used when prescribing opioids at any dosage and providers should carefully reassess evidence of benefits when increasing dosages to ≥50 MME/day as many patients do not experience benefit in pain or function from those doses. The 2022 guidelines continue to recommend assessing risks and benefits within 1-4 weeks of starting therapy and regularly with continued opioid use, as was recommended in the 2016 guidelines. However, an additional statement was added which recommends carefully weighing risks versus benefits any time a change in dosage occurs.

Another new statement in the 2022 guidelines discourages abrupt discontinuation or rapid dose reductions in opioids unless there are warning signs of impending overdose or other life-threatening issues. The 2016 guidelines did suggest tapering opioid dosages to lower doses or discontinuing altogether if benefits did not outweigh harms, but did not address abrupt discontinuation. As with the 2016 guidelines, clinicians should still evaluate patients for risk of opioid related harms and offer naloxone to mitigate risk, and should exercise caution when prescribing opioids in patients with concomitant benzodiazepines or other CNS depressants.

Another change is related to duration for opioid prescriptions for acute pain. In the 2016 guidelines, it was recommended that prescriptions for three days or less would be sufficient for most, and rarely would need to exceed seven days. The 2022 guidelines do not specify a duration but rather state prescriptions for opioids should be written for a quantity no greater than needed for the expected duration of pain (which is severe enough to require opioids). The final recommendation from the 2022 guideline notes clinicians should offer or arrange treatment for patients with opioid use disorder and discourage detoxification on its own without medications for opioid use disorder.

Discussion and Clinical Impact: It is clear the 2022 guidelines were updated from 2016 to provide more flexibility for both patients and clinicians. Some may struggle with the ambiguity of the 2022 guidelines as they may be familiar with more straightforward recommendations. These guidelines should be used as a clinical tool to help guide therapy recommendations and improve communication between clinicians and their patients.

References:

1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1.\
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1.