CDC Releases New Guidelines for Opioid Prescribing

In what many consider a step backward for the movement towards cautious, conservative opioid prescribing, the CDC has softened its recommendations on how doctors should prescribe potentially addictive painkillers.

On November 3rd, 2022, the Centers for Disease Control and Prevention released new opioid prescribing guidelines, an updated list of recommendations that shifted away from the original 2016 release on a few key issues. While the new recommendations provide a more nuanced set of guidelines for doctors, some will find fault in the guidelines’ more relaxed approach to prescribing addictive opioid painkillers.

A Quick Look at What Changed

Skyrocketing opioid prescribing from 1999 to 2016 caused millions of Americans to become addicted to opioids. According to the CDC, the opioid prescribing rate and the opioid overdose rate increased at almost the same rate (400%) between 1999 and 2010, which acted as an incentive for the CDC to create its initial 2016 prescribing recommendations.¹

But as pharmaceutical opioid prescribing rates declined following the 2016 guidelines, the CDC came under pressure for “creating a barrier to care” for patients who suffer from acute or chronic pain.²

Some of the most significant changes in the recommendations include the following:

• The CDC no longer suggests doctors limit opioid treatment for acute pain to three days.

• The CDC has dropped the recommendation that doctors avoid increasing dosages to a level equivalent to 90 milligrams of morphine per day.

• For patients receiving higher doses of opioid painkillers, the CDC is now urging doctors to avoid abruptly halting opioid treatment unless there are indications of a life-threatening danger (like a high overdose risk).

A more detailed examination of the “What’s Changed” page of the new guidelines reveals the CDC is granting more agency on when, how, and to what extent doctors can prescribe opioids. While one can say that we should trust doctors to make wise, informed recommendations for their patients, granting doctors total freedom in prescribing was part of what led to the opioid epidemic in the first place.³

While some are celebrating the more nuanced opioid prescribing publication from the CDC, others are concerned the release will be viewed as a rollback in conservative prescribing guidelines and that it may lead to a spike in prescribing in the years ahead.

The CDC’s Twelve Recommendations, Summarized

The new prescribing guidelines can be summarized in twelve distinct recommendations:⁴

1. Non-opioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should always maximize the use of non-pharmacologic and non-opioid pharmacologic therapies. There are many ways to treat pain, and Opioids are just one of them.

2. Non-opioid therapies are still preferred for subacute and chronic pain. Quoting the CDC, “Clinicians should maximize use of non-pharmacologic and non-opioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.”

3. When prescribing opioids for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids, not extended-release or long-acting opioids.

4. Clinicians should always prescribe the lowest effective doses for ‘opioid-naïve’ patients with acute, subacute, or chronic pain.

5. Clinicians must always carefully weigh benefits and risks and exercise care when adjusting an opioid dosage.

6. Clinicians should still be very cautious when prescribing opioids and prescribe no greater quantity than needed for the expected duration of pain that is severe enough to require opioids. Once pain levels diminish below the threshold where opioids are needed, clinicians should prescribe non-opioid options like over-the-counter pain relievers.

7. Clinicians should always evaluate benefits and risks with patients, ideally every 1–4 weeks from starting opioid therapy. Risks should always be evaluated when considering continuing opioid therapy.

8. Mitigating risk is also a must. Clinicians should work with patients to incorporate strategies to mitigate risk, including offering naloxone and exploring alternatives to pain relief if addiction or opioid dependency symptoms become apparent.

9. Clinicians should make full use of prescription drug monitoring program (PDMP) data to determine whether the patient they are treating is receiving opioid dosages from other doctors that might then put the patient at high risk for overdose.

10. Clinicians must always determine what other medications their patient is taking before prescribing opioids. Toxicology testing should be used to determine what medicines the patient is taking.

11. Clinicians should use extreme caution when prescribing opioid pain medication and benzodiazepines concurrently.

12. Finally, physicians should offer a range of treatment options. Opioids should not be the first or only treatment option that physicians reach for.

What to Make of the New Recommendations

One of the primary goals of the 2022 CDC Prescribing Guidelines was to provide doctors with recommendations, not hard and fast rules to follow when prescribing opioids. Christopher Jones, acting director of the CDC’s National Center for Injury Prevention and Control, commented on this point. He said, “The guideline recommendations are voluntary and meant to assist and guide shared decision-making between a clinician and patient. The guidelines should not be used as a rigid standard of care or inflexible policy or law. It’s not meant to be implemented by clinicians, health systems, insurance companies, and governmental entities at absolute limits of policy or practice.” That’s a shift from the 2016 guidelines, which outlined clear requirements for physicians regarding when and how to prescribe opioids.⁵

2022’s guidelines carry much of the same cautionary language and conservative-minded prescribing suggestions. However, it is a step backward for the CDC not to give doctors sensible yet definitive limits on opioid prescription dosages and durations. One of the aspects of the CDC’s 2016 recommendations that was arguably the key to getting doctors to reduce their prescribing trends was the recommendation to avoid increasing dosage to ≥90 MME/day (MME/day stands for morphine milligram equivalent/day) and to keep prescriptions to three days or less, rarely more than seven days for acute pain.⁶

The recommendation to “use the lowest effective dose possible for the shortest duration of time possible” is all but gone from the 2022 recommendations. Looking to the future, patients will have to hope that their doctors saw the wanton destruction wrought by overprescribing through the 2000s and 2010s. Patients will have to put their faith in their doctors and hope that their doctors know to be conservative with opioid prescribing.

And perhaps most importantly, patients shouldn’t just leave it up to their doctors. Patients should do their own research and get informed about the harms and addiction risks that come with all forms of opioid pain relievers. Patients should insist they have access to non-opioid pain relief options to avoid addiction risk.

Sources Cited: