Opioid Prescribing: CDC Guidelines and More

From prohibitive practices that failed to treat pain in the early 90s to over-prescribing that caused the opioid overdose epidemic still ongoing today, prescription opioids have had a complicated history with healthcare professionals in the US.

The Centers for Disease Control and Prevention (CDC) issued clinical practice guidelines in 2016 that aimed to course-correct the use of opioid therapy. Due to multiple complaints that affected patients’ access to life-saving measures, it was revised and rereleased in 2022.

Here’s everything you need to know about opioid prescribing trends and how the CDC seeks to correct opioid prescription issues.

A Background on Opioid Prescribing Trends

In the early 90s, many doctors avoided initiating opioid therapy for pain management due to their addictive nature, in what was colloquially known as “opio-phobia.” Back then, the number of opioid-related overdoses and deaths remained at bay, although many patients struggled to get a prescription for acute pain or even after having major surgery.

By the mid-to-late 90s, the US healthcare system saw a significant shift in how prescribing opioids was approached. Due to lobbying from non-profit groups, as well as from some pharmaceutical companies, the attitude toward opioid prescribing for chronic pain and smaller injuries relaxed.

This brings us to the new millennium, as the opioid crisis was looming in the form of a disproportionate number of opioid prescriptions. The risk of prescription opioid overdose was at an all-time high in 2007, when 78% of all opioid overdose deaths were attributed to them. However, the number of prescriptions wouldn’t peak until 2012, when there were 81.3 doses of opioids prescribed per 100 persons in the US.

This became a public health crisis as prescription opioids became a gateway drug for other illicit opioids. Patients who developed a dependence after taking opioids for chronic pain soon found it cheaper to move on to more potent drugs, such as heroin and fentanyl.

While the percentage of prescription opioid overdose deaths plummeted to 24% in 2020, fentanyl and heroin overdose deaths continue to rise.

In 2016, the CDC’s guidelines for prescribing opioids for pain management were released. It incentivized states to implement changes that limited overprescribing of opioids, which included:

• Limiting the length and daily dosage of opioid prescriptions for acute pain.
• Limiting the maximum dose of prescribed opioids for chronic pain under 90 morphine milligram equivalents (MME) per day.
• A requirement for prescribing the anti-overdose drug, Naloxone, besides the opioid prescription.
• State policies that created and enforced Prescription Drug Monitoring Programs (PDMPs).

These measures helped contain the problem, with the number of prescriptions dropping to 59 per 100 persons in 2017. But on the flip side, opioid treatment wasn’t prescribed for patients who needed it due to some of these restrictions.

Which brings us to the CDC’s clinical practice guidelines for prescribing opioids in the present day.

The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain

The main concern of the current guidelines proposed by the CDC for opioid treatment prescription is harm reduction. In fact, the guideline aims to decrease the number of opioid use disorder cases while providing pain management to people who stand to benefit the most from opioid therapy.

The CDC guideline includes the following recommendations:

Key Recommendations

• Before starting opioid therapy, a clear list of realistic goals should be established when it comes to pain management and function restoration. Resorting to opioid therapy should only happen if the benefits outweigh the potential risks.
• The risk factors that lead to opioid use disorder, dependence, and overdose should be laid out, and a decision regarding initiating opioid therapy should be made based on the evidence.
• Using Prescription Drug Monitoring Programs (PDMPs), the patient’s prescription drug use history should be carefully reviewed before prescribing opioids. It should also be reviewed periodically during the course of the opioid treatment.
• Continued assessment of the patient’s use of prescribed controlled substances or illicit drugs should be carried out via regular urine drug tests.
• An opioid and Benzodiazepine co-prescription should be avoided whenever possible due to the higher risk of overdose.
• Overdose prevention tactics, such as prescribing naloxone for high-risk patients, should be carried out.
• For patients with opioid use disorder (OUD), medication-assisted treatment should be carried out to mitigate acute withdrawal symptoms using methadone and buprenorphine prescriptions, as well as behavioral therapies that reduce the risk of relapse.

For Acute Pain Management

• The lowest effective dose of immediate-release opioids should be prescribed to manage severe pain after an injury or major surgery.
• If the treatment for acute pain was longer than 3 days but shorter than 7 days, dose tapering for 2 days at 50% of the dose is recommended.
• If the treatment was longer than 7 days but shorter than a month, a slower taper is recommended to mitigate potential withdrawal symptoms.

For Chronic Pain Management

• Nonpharmacologic interventions and nonopioid pain medications are preferred modes of treatment for chronic pain patients. If opioid therapy is required, it should be combined with physical and nonopioid pharmacologic therapies for best results.
• If prescribing opioids for chronic pain, extended-release/long-active opioids should be avoided. Instead, the lowest effective dose of immediate-release opioids should be prescribed.
• Within 4 weeks of initiating or increasing dosages of opioid therapy for chronic pain patients, the benefits and risks should be examined against the treatment goals. This should be repeated every 3 months of using opioids for chronic pain.
• If the risk factors are numerous and outweigh the benefits, a plan to taper the dose and eventually replace opioid prescriptions with nonopioid or nonpharmacologic therapy options should be put in place.

Wrapping Up

The current Centers for Disease Control and Prevention (CDC) recommendations for opioid prescribing aim to treat pain while reducing opioid-related harms like dependence, overdose, and even death.

Since prescription opioids have been proven to be gateway drugs for more serious drug abuse, like heroin and fentanyl, reducing the number of prescriptions is essential to stop the current opioid overdose crisis.

If you or your loved one are facing opioid use disorder or addiction, there’s still a chance to prevent serious risks. Book an appointment today with one of our licensed clinicians to get started on your treatment journey.