T

he CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2022, 2022 Clinical Practice Guideline updates and replaces the 2016 Guideline for Prescribing Opioids for Chronic Pain. Importantly, they do not apply to patients experiencing pain related to sickle cell disease, cancer-related pain, palliative care and end-of-life care.

What’s New?

• Guiding principles for implementing recommendations.
• New data to expand content on prescription opioids for acute pain.
• New guidance on subacute pain.
• Health equity and disparities in the treatment of pain

Five Guiding Principles for Implementing Recommendations

1. Acute, subacute, and chronic pain needs to be appropriately assessed and treated independent of whether opioids are part of a treatment regimen.
2. Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount.
3. A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes¹ and well-being of each person is critical.
4. 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.
5. 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.

The 12 recommendations found in the CDC Clinical Practice Guideline for Prescribing Opioids for Pain – United States, 2022 can be summarized by the following actions:

1. Determining whether or not 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.

What’s Changed?

The 2022 Clinical Practice Guideline (hereon in referred to as the Guidelines) broadens the scope from primary care physicians to include additional clinicians whose practice include prescribing opioids in an outpatient setting for patients 18 years and older. The Clinical audience includes outpatient clinicians such as dentists, emergency clinicians, surgeons, occupational medicine physicians, physical medicine and rehabilitation physicians, neurologists, and obstetricians and gynecologists. The g=guidelines promote integrated management and collaborative working relationships among clinicians, including behavioral health specialists, psychologist, pharmacist and nurses.

The Guidelines clearly delineate recommendations that apply to patients who (1) are being considered for initial treatment with prescription opioids, or (2) already receiving opioids as part of their ongoing pain management.

The benefit and risk of opioids change over time and the Guidelines outline situations when clinicians should consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy. The revised and expanded guidance provide support to opioid tapering for key topics when indicated including, determining whether, when and how to taper opioids; providing advice to patients prior to tapering; pain management during tapering; behavioral health support during tapering; tapering rate; management of opioid withdrawal during tapering; challenges to tapering; and continuing high-dosage opioids.

Opioid dosage guidance was updated regarding: suggestions for lowest starting dose for opioid-naïve patients; morphine milligram equivalent doses for commonly prescribed opioids; and the approach to potential dosage increases, emphasizing principles for safe and effective pain treatment. The Guidelines provide guideposts to help inform clinician-patient decision-making, and are not intended to be used as an inflexible and rigid standard of care. Considerations for continuation of opioids for chronic pain advises: using cautions when prescribing opioids at any dosage; carefully evaluate individual benefits and risks when increasing dosage; and avoid increasing dosage above levels likely to yield diminished returns in benefits relative to risks to patients.

In relation to non-opioid therapies, the Guidelines expanded guidance on nonopioid pharmacologic therapies, and nonpharmacologic therapies. They state all patients should receive treatment that provides the greatest benefits relative to risks.

In summary, the Guidelines emphasize:

• Individualized patient care
• Safe and effective pain management options
• Improving communication between clinicians and patients so they can make decisions together about the best care for the patient
• Reducing risks associated with opioid pain therapy, including opioid use disorder, overdose, and death

The evidence continues to support the same cautions with the morphine milligram equivalent (MME) thresholds. This is based on findings that the benefits of high-dose opioids for pain are not well established. Many patients do not experience benefit in pain or function from increasing opioid dosages to ≥50 MME/day, but are exposed to progressive increases in risk as dosage increases. Therefore, before increasing total opioid dosage to ≥50 MME/day, clinicians should pause and carefully reassess evidence of individual benefits and risks. If a decision is made to increase dosage, clinicians should use caution and increase dosage by the smallest practical amount. Additional dosage increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits for pain and function relative to risks to patients as dosage increases further. Clinicians should carefully evaluate a decision to further increase dosage on the basis of individualized assessment of benefits and risks and weighing factors such as diagnosis, incremental benefits for pain and function relative to risks with previous dosage increases, other treatments and effectiveness, and patient values and preferences.

ExamWorks Compliance Solutions’ Doctors of Pharmacy offer opioid risk-benefit evaluation, potential opioid tapers, risk mitigation strategies, optimization of nonopioid agents, alternatives to high cost Medicare-covered medications, and clarification of drug regimens to provide the most accurate and defensible MSA. The goal of the program is to impact medication therapy to improve safety and clinical outcomes, and mitigate MSA drug costs by consulting with the treating provider on the clinical rationale for the medication regimen. ExamWorks utilizes technology and compendia databases, which are recognized and supported by the CMS to support inclusion or exclusion of a drug under the Part D benefit. We will continue to monitor changes in medication pricing as well as availability of generic equivalents within the marketplace.

For questions about medications, please contact Nahla D. Rizkallah, PharmD, MSCC, at 678.256.5086 or nahla.rizkallah@examworkscompliance.com.

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