Loren Bonner
CDC’s updated guidelines on pain management are “a step in the right direction,” said Chris Herndon, PharmD, BCACP, FASHP, FCCP. Most pain experts, like Herndon, are pleased with the new guidance, which covers acute, subacute, and chronic pain, and replaces the controversial 2016 CDC opioid guideline for chronic pain.
“Removing the ‘line in the sand’ doses will hopefully remove some of the misconceptions and stigma around opioids,” said Herndon, who is a professor at Southern Illinois University Edwardsville School of Pharmacy.
CDC’s Clinical Practice Guideline for Prescribing Opioids for Pain throws out the rigid numbers and hard thresholds for pain medication doses and duration that were emphasized in the recommendations from the 2016 version. The 2016 CDC guidelines—which were simply intended to “guide” therapy—turned into policies and practices that, for example, encouraged hard limits and in some cases, resulted in abrupt tapering of opioid drug doses. Insurance companies, for instance, put coverage restrictions in place for opioid prescriptions above a certain morphine milligram equivalent per day. Turning back these laws and policies is difficult, however, and the new guidelines will take time to reverse the hard limits that insurance companies and others have enacted.
In the 2022 guidance, CDC promotes tailored care for patients through shared decision-making between patients and their care teams, which includes pharmacists.
“The guideline explicitly recognizes various roles for pharmacists in integrated pain management as part of care teams,” said Anne Burns, RPh, former vice president of professional affairs at APhA. Burns was part of a workgroup for the guideline. “The new recommendations and user-friendly format should help pharmacists in providing individualized pain care to their patients,” she said.
On these care teams, pharmacists can, for example, help with tapering services, coprescribing of naloxone, monitoring prescription drug monitoring programs (PDMPs), and be involved when opioids are coprescribed with other central nervous system depressants.
In a press statement, CDC said the updated guideline is a clinical tool to improve communication between clinicians and their patients and empower them to make informed decisions about safe and effective pain care. The recommendations are voluntary and provide flexibility to clinicians and patients to support individualized, patient-centered care. According to CDC, the guidelines should not be used as an inflexible, one-size-fits-all policy nor should they replace clinical judgment about personalized treatment.
“Patients with pain should receive compassionate, safe, and effective pain care,” said Christopher Jones, PharmD, MPH, acting director of CDC’s National Center for Injury Prevention and Control, in the press statement. “We want clinicians and patients to have the information they need to weigh the benefits of different approaches to pain care, with the goal of helping people reduce their pain and improve their quality of life.”
The new clinical practice guideline is intended for clinicians who are treating outpatients aged 18 years and older with acute (duration of less than 1 month), subacute (duration of 1–3 months), or chronic (duration of more than 3 months) pain, and excludes pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care.
Specifics
The new CDC guidance addresses 4 key areas for pain management: 1) determining whether to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow up, and 4) assessing risk and addressing potential harms of opioid use.
With 12 recommendation statements in total, each is followed by considerations for implementation and a rationale for the recommendation.
In general, the recommendations state that clinicians should not consider opioids as first-line or routine therapy for many types of acute, subacute, or chronic pain. Nonopioid therapies, like prescription gabapentin and OTC nonsteroidal anti-inflammatory medication, are often preferable for several types of acute pain, CDC pointed out. In the subacute timeframe of patients receiving opioids for 1 to 3 months, CDC recommends that clinicians carefully reassess treatment goals, benefits, and risks before continuing any opioid treatment.
The new guideline reinforces the 2016 guideline’s recommendation for judicious use of opioids for chronic pain.
In a commentary about the new guideline published in NEJM, authors noted that clinicians should maximize use of nonopioid therapies for chronic pain and consider initiating opioid therapy only if the expected benefits for pain and function are anticipated to outweigh the risks.
In the commentary, guideline coauthor Debbie Dowell, MD, MPH, chief clinical research officer for CDC’s Division of Overdose Prevention, and colleagues wrote, “when opioids are needed [for chronic pain], clinicians should initiate therapy at the lowest effective dosage, carefully evaluate individual benefits and risks when considering increasing dosages and avoid increasing the dosage above levels likely to yield diminishing returns in benefits relative to risks.
“These principles do not imply that nonpharmacologic and nonopioid pharmacologic therapies must all be tried unsuccessfully in every patient before opioid therapy is offered. Rather, expected benefits specific to the clinical context should be weighed against risks before therapy is initiated.”
Like the 2016 guideline, the 2022 guideline says that when opioids are needed for acute pain, they should be prescribed at the lowest effective dose and for no longer than the expected duration of pain severe enough to warrant opioids. Tapering is recommended when opioid treatment is discontinued after being used continuously for more than a few days, according to the NEJM commentary.
Equitable access
According to CDC, the 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.”
Herndon said the guidelines do a good job of ensuring proper interpretation and use of the recommendations as well as the patient population to which they pertain.
“It’s important to remember that any opioid exposure is associated with some increased risk and that the risk is dose-dependent,” he said. “However, to assume that 48 mg of MME daily has less risk than 51 mg of MME daily, especially without considering patient-specific factors, creates barriers to access that have proven to be detrimental to patients.”
Writing in the NEJM commentary, Dowell and colleagues suggest finding ways to allow patients whose pain unexpectedly persists to gain timely access to re-evaluation in order to promote more equitable access and reduce barriers to high-quality care.
The guideline also cautions clinicians about potential bias in interpreting data from PDMPs and toxicology tests.
Five new guiding principles have been added to help clinicians put the recommendations into practice and support appropriate, individualized care. They include
Acute, subacute, and chronic pain needs must be appropriately assessed and treated independently of whether opioids are part of a treatment regimen.
Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstance of a specific patient is paramount.
A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.
Special attention should be given to avoid misapplying this clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended and potentially harmful consequences for patients.
Clinicians, practices, health systems, and payers should vigilantly attend to health inequities; provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities; and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons.
Best available evidence
According to the CDC press statement, the agency followed a rigorous scientific process using the best available evidence and expert consultation to develop the 2022 Clinical Practice Guideline.
An independent federal advisory committee, peer reviewers, and members of the public reviewed the draft updated guideline, and CDC revised it in response to this feedback, they noted. An opioid workgroup reviewed the guideline and provided recommendations.
CDC also engaged with patients with pain, caregivers, and clinicians to gain insights and gather feedback from people directly affected by the guideline.
“The science on pain care has advanced over the past 6 years,” said Dowell, in the CDC press statement. “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 recommendations in the 2016 CDC Opioid Prescribing Guideline were based on a systematic review of the best available evidence at the time, along with input from experts and the public.
The 2022 guideline also supports the primary prevention pillar of the HHS Overdose Prevention Strategy—supporting the development and promotion of evidence-based treatments to effectively manage pain.
For example, the new guidance suggests that clinicians work with patients to incorporate plans to mitigate risks, including offering naloxone. ■
Intended use of CDC’s 2022 Clinical Practice Guideline for Prescribing Opioids for Pain
This clinical practice guideline is
- A clinical tool to improve communication between clinicians and patients and empower them to make informed, person-centered decisions related to pain care together.
- Intended for primary care clinicians and other clinicians providing pain care for outpatients aged ≥18 years with
- Acute pain (duration of <1 month),
- Subacute pain (duration of 1–3 months), or
- Chronic pain (duration of >3 months)
- Intended to be flexible to enable person-centered decision-making, taking into account a patient’s expected health outcomes and well-being.
This clinical practice guideline is not
- A replacement for clinical judgment or individualized, person-centered care.
- Intended to be applied as inflexible standards of care across patients or patient populations by health care professionals, health systems, pharmacies, third-party payers, or governmental jurisdictions or to lead to the rapid tapering or abrupt discontinuation of opioids for patients.
- A law, regulation, or policy that dictates clinical practice or as a substitute for FDA–approved labeling.
- Applicable to
- Management of pain related to sickle cell disease,
- Management of cancer-related pain, or
- Palliative care or end-of-life care; or
- Focused on opioids prescribed for opioid use disorder.
Adapted from Dowell et al. MMWR Recomm Rep. 2022;71:1–795. doi: http://dx.doi.org/10.15585/mmwr.rr7103a1