New CDC opioid guidelines emphasize flexibility in treating pain

Federal health officials on Thursday updated their recommendations for using opioids to treat pain, removing specific dose and duration targets that pain experts said had caused unintended harm.

The new guidance, released by the Centers for Disease Control and Prevention, reflects the evolution in thinking of how opioids should be used, and the reality of how they are being used. The original guidelines, issued in 2016, helped further drive down opioid prescribing levels that had been in decline since 2012, as the country grappled with its legacy of overprescribing that contributed to the overdose epidemic. But critics contended the 2016 guidelines, while helping limit new prescriptions, introduced other harms by leading to unsafe dose reductions for people already on opioids and some long-term patients being cut off from medication they depended on.

A major theme of the 2022 guidelines is that people with pain need individualized care, and that prescribers need to calibrate doses and timeframes to meet a patient’s needs, all while still trying to minimize the harms that can come with opioid use.

The guidelines no longer say, for example, that doctors should “avoid increasing dosage” to 90 morphine milligram equivalents or more per day or to “carefully justify” such a decision, as the 2016 version did. Instead, they say that “clinicians should prescribe the lowest effective dosage.”

The guidance also no longer says that for acute pain, prescriptions lasting “three days or less will often be sufficient; more than seven days will rarely be needed.”

The original guidelines were meant to be voluntary recommendations, but some companies and policymakers interpreted the suggested dose limits as hard ceilings. One result was that some chronic pain patients, who had long been on higher doses, had their doses “tapered” to lower levels. Experts warned that overly aggressive and involuntary tapers were unsafe, leading to a resurgence of pain and withdrawal symptoms that might drive patients to seek out illicit sources of relief or even to suicide.

The original CDC guidelines became a major point of criticism from the chronic pain community, which argued that they contributed to a broader fear of regulatory and legal scrutiny around opioids that pushed doctors to get out of prescribing, particularly at high doses or for long periods of time.

The authors of the original guidelines warned in 2019 that their recommendations were being misapplied. And in a commentary also published Thursday, the authors wrote that they revised their recommendations because the original document was improperly cited as a justification for certain policies that restricted opioid access.

“Such misapplication, including inflexible application of recommended dosage and duration thresholds, contributed to patient harms, including untreated and undertreated pain, rapid opioid tapers and abrupt discontinuations, acute withdrawal symptoms, and psychological distress, in some cases to leading to suicidal ideation and behavior,” they wrote in the New England Journal of Medicine. “These experiences underlined the need for an updated guideline reinforcing the importance of flexible, individualized, patient-centered care.”

The authors said CDC would monitor for “unintended effects” of the new guidelines, and on a call with reporters Thursday, Christopher Jones, the acting director of CDC’s National Center for Injury Prevention and Control, said that the agency would be working with clinical organizations and patient groups to share information about the updates. If insurers or individual prescribers continue to misapply the guidelines, CDC will use that as “an educational opportunity” to provide accurate guidance on pain treatment and tapering, Jones said.

“If policies are put in place that have one-size-fits-all, rigid standards of care, that is inconsistent with the goals and intent of this guideline,” Jones said.

The finalized guidelines released Thursday broadly match a draft version issued in February, but there were some revisions that Kate Nicholson, the executive director of the National Pain Advocacy Center, said she saw as an improvement. For one, the guidelines stress more frequently that they are voluntary and that patients need individualized care. The section on whether providers should initiate a taper of a patient’s dose and how to go about doing so is also more careful, Nicholson said.

More broadly, the CDC is signaling that it’s going to watch for the further misapplication of these guidelines, she said.

“They’re really saying to payers and health systems and states, you need to course correct,” Nicholson said.

The 2022 guidelines still include plenty of caution about the use of opioids. With the updated guidelines, the authors said, they were able to incorporate additional research that supports the use of non-opioid treatments for many types of routine acute pain, whether other types of medications or interventions like exercise and physical therapy. Opioids are still an important tool for more intense acute pain, following traumatic injuries or major surgeries, they say. When prescribing opioids, providers should use immediate-release medications instead of extended-release or long-acting drugs, according to the guidance.

Prescribers should also weigh carefully whether to continue someone on opioids after three months “to prevent unintentional initiation of long-term opioid therapy,” the CDC experts wrote in their commentary.

The guidelines are an attempt to strike a balance between avoiding disruptions to people’s lives and limiting the risks that some see as stemming from long-term opioid use, including addiction, mental health problems, and, perhaps, more sensitivity to pain. Some experts doubt whether opioids are an effective treatment for chronic pain generally.

The recommendations still encourage reductions in dosages when it can be done safely and in collaboration with a patient. They also provide guidance for “whether, when, and how to taper opioids,” recommending that doctors find the lowest possible dose that still resolves patients’ pain. But the message is that dose reductions need to be done carefully and slowly — perhaps a 10% dose reduction or less a month — after weighing the possible risks of tapering. Patients should not have their doses abruptly halted or reduced drastically, CDC officials stressed.

While much of the debate about the guidelines has focused on their implications for chronic pain patients, the guidelines address using opioids as a pain treatment broadly, with recommendations for determining whether to initially offer opioids for pain care, selecting opioids and doses, and monitoring patients for follow-up.

Like the 2016 version, the new guidelines are not meant to apply to patients with cancer or sickle cell disease, nor do they apply to end-of-life pain care.

“Ideally, new recommendations should result in greater and more equitable access to the full range of evidence-based treatments for pain, more judicious initial use of opioids, and more careful consideration and management of benefits and risks associated with continuing, tapering, or discontinuing opioids in patients who are already receiving them long term,” the authors wrote in their commentary.

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