Prescribing Opioids for Pain: Exploring the CDC Clinical Practice Guidelines

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Podiatric physicians are well-aware of the major clinical, social, and economic impact that pain imparts in communities locally and globally. Sources previously acknowledged ongoing disparities in pain management with respect to factors such as race or ethnic group, gender, socioeconomic status, and population density, among others.¹ Over the past several years, evolving guidance has emerged regarding safe and effective treatment of pain.^2–4

Within the practice of medicine, including podiatric medicine and surgery, opioids remain a part of many pain management pathways. However, it is vital that providers understand and incorporate the latest guidance into their practices in order to avoid opioid harm while adequately addressing pain.

Understanding the Recent Evolution of Prescribing Guidelines

In 2016, Dowell and colleagues published the “Centers for Disease Control and Prevention (CDC) Guidelines for Prescribing Opioids for Chronic Pain.”² This document aimed to help primary care providers to better evaluate the risk differential of opioids with respect to treating chronic pain. The reality presented itself that within several years of the release of these guidelines, data noted an accelerated reduction in opioid prescribing (including potentially high-risk prescribing) and an increase in utilization of nonopioid pain medications.^3,4 However, at the same time, state laws, regulations, and policies did not always align with the 2016 guidelines.^3,4

Furthermore, in my observation, misapplication of these guidelines emerged, including inflexible application of recommended dosage and duration thresholds. This may have contributed to untreated and/or undertreated pain, overly rapid opioid tapers and abrupt discontinuations, with impacts such as acute physical withdrawal, psychological distress, and severe consequences to mental health and well-being.

Such experiences underlined the need for an update to opioid prescribing guidelines to reinforce the importance of flexible care tailored to the individual patient and their unique factors. Moreover, the last several years yielded new evidence supporting expanding this guidance in scope and detail regarding scenarios such as acute pain, opioid tapering, and specific treatment approaches for different types of pain.⁴

In 2022, Dowell and an updated team released a new CDC Clinical Practice Guideline, which applies to opioid prescribing for adult outpatients with pain.⁴ While it did not address scenarios such as sickle cell disease, cancer-related pain, palliative, or end-of-life care, the updated guideline did elaborate on varying pain durations (acute and subacute), extended the guidance beyond primary care, and included patients being discharged from hospitals, emergency departments, or other facilities.⁴

The 2022 guidelines share a goal of facilitating equitable, effective, personalized, and safe pain management.⁴ Ideally, this would include judicious opioid use based on thoughtful risk analysis, access to a comprehensive range of proven nonopioid-based pain treatments, and careful consideration of pathways unique to individuals already receiving long-term opioids.⁴

What Does the Latest Guidance Say?

A review of the 2022 guidelines reveals 12 recommendations and their associated rationale, along with examples that encourage practical flexibility in applying them.⁴ The recommendations address the following subtopics:⁴

• Deciding if initiating opioids is the right choice for a patient with pain
• Appropriate opioid and dose selection
• Best practices in the duration of opioids and effective follow-up
• Risk assessment and harm avoidance in opioid use

It is also important for prescribers to understand several concepts regarding implementation of these guidelines that the authors present in their paper.⁴

• Acute, subacute, and chronic pain warrant assessment and appropriate treatment regardless of whether opioids are part of the treatment plan.
• The presented recommendations are voluntary and meant as a support to care decisions. Flexibility to acknowledge a patient’s specific clinical scenario is vital.
• The authors promote a multimodal and multidisciplinary approach to pain management that acknowledges the patient’s physical and mental health, along with any need for services or supports.
• Stakeholders should take particular caution to avoid misapplication of these guidelines outside of their intended use.
• Attention to mitigating health inequities should be paramount. This may include accessible communication pathways, and expanded access to effective pharmacologic and non-pharmacologic treatment choices.

Recommendations From the 2022 CDC Practice Guidelines

Recommendation 1. This recommendation contends that nonopioid therapies are at least as equally effective as opioids for common acute pain cases.^1,4 The authors recommend maximizing nonopioid and nondrug options as appropriate on a case-by-case basis, unless the benefit of an opioid is likely to outweigh the risks. If one initiates an opioid, the prescriber should first discuss the benefits, known risks, and realistic expectations of such therapy.^1,4

Recommendation 2. For chronic pain, nonopioid treatment is preferred for subacute and chronic pain scenarios. Clinicians should follow the same pathway as in Recommendation 1, and add in a clear determination of treatment goals with respect to pain levels and function. The authors also note that collaboration should take place to plan for safe opioid discontinuation if the risk/benefit analysis becomes unfavorable.^1,4

Recommendation 3. Initiation of opioid therapy for acute, subacute, or chronic pain should utilize immediate-release opioids instead of extended-release or long-acting formulations.^1,4

Recommendation 4. A prescriber should choose the lowest effective dosage of opioid when initiating such therapy for opioid-naïve patients with acute, subacute, or chronic pain. In cases of subacute or chronic pain, opioid continuation should be a cautious undertaking, regardless of dose. Individual benefits and risks must remain a consideration when continually evaluating dosage.^1,4

Recommendation 5. For patients already receiving opioid therapy, prescribers should carefully consider benefits and risks with respect to changing dosage. If choosing continued opioid therapy, optimizing concurrent nonopioid therapies is also wise. Optimized nonopioid therapy should also be a part of the plan when choosing to discontinue or lower opioid dosage, based on risk-benefit analysis. Careful tapering to a lower dose or thoughtful discontinuation plans are key. Sudden discontinuation and/or rapid dose reduction is not advisable, unless a life-threatening issue is identified, such as an impending overdose.^1,4

Recommendation 6. Opioids prescriptions for acute pain should be for no greater a quantity/duration than the expected duration of pain levels severe enough to require said opioids.^1,4

Recommendation 7. Within 1–4 weeks of starting or escalating opioid therapy for subacute or chronic pain, and regularly throughout continued opioid therapy, the provider should conduct updated risk-benefit analyses.^1,4  

Recommendation 8. Prescribers should include patients in the risk evaluation before starting and during continuation of opioid therapy, by discussing these risks directly. Additionally, collaborating with patients on risk mitigation, such as offering naloxone, may also be wise.^1,4

Recommendation 9. Review of a patient’s controlled substance history using one’s state prescription drug monitoring program should take place when initially prescribing opioids for acute, subacute, or chronic pain. A follow-up query of the same system periodically during opioid therapy for chronic pain will also assist in identifying any presence of dosage or medication combinations that could prove dangerous to the patient.^1,4  

Recommendation 10. Toxicology testing may be indicated when prescribing opioids for subacute or chronic pain in circumstances when clinicians have concern to assess for the presence of pertinent prescribed medications as well as other prescribed and nonprescribed controlled substances.^1,4

In Conclusion

The podiatric physician should appreciate the role this newest clinical practice guideline aims to play in improving equitable access to safe and effective pain management for patients. With a focus on improving function and quality of life these guidelines aspire to assist prescribers in identifying and reducing risks associated with prescription opioids. Further, the lower extremity specialist should note that the CDC will continually evaluate this clinical practice guideline, including the impact on outcomes, prescribing behaviors, and health disparities, including intended and unintended consequences.

Lastly, central to success of practice guidance such as this is the communication between clinician and the patient. Comprehensive conversations about benefits and risks of opioids are paramount to optimizing treatment decisions for patients in pain. Hopefullly, the above review of timely clinical practice guidelines will help inform patient-centered decisions on pain management in podiatric practices.

Dr. Smith is a Fellow of the National Academies of Practice, and is a Registered Pharmacist. He is a national lecturer on reducing opioid harm and related topics.

For further reading on opioids, see “What Podiatrists Should Know About Non-Pharmacologic Options for Pain Control”, “The Ugly Truth: Opioids and the History of the Opioid Epidemic”,“How Can Foot And Ankle Surgeons Responsibly Manage Post-Op Pain With Opioids?” or “A Guide To Non-Opioid Alternatives For Pain Management.”

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;71:1-95.
2.    Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain--United States, 2016. JAMA. 2016;315(15):1624-1645.
3.    Humphreys K, Shover CL, Andrews CM, et al. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet. 2022 Feb 5;399(10324):555-604.
4.    Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. Prescribing opioids for pain - the new CDC Clinical Practice Guideline. N Engl J Med. 2022 Dec 1;387(22):2011-2013.