The latest CDC guidelines were released on November 4, 2022 pertaining to acute and chronic pain treatment with opioid medications. Even though the proposal included goals to "remove caps" on opioid dosing, the new guidelines continue to have certain blanket dose recommendations, although with less of a policing tone.
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Background:
In 2016, the CDC set "caps" for opioid prescribing of 90 morphine milligram equivalents. Even though the guidelines weren't intended to be a strict cutoff, the authors wrote in a New England Journal of Medicine article in 2019 that the recommendations were misapplied and were wrongly being used to cut off patients or to justify unsafe tapers. Consequently, many doctors and patients say the 2016 guidelines led to a crisis of untreated pain. A 2017 study showed that because of these guidelines 84% of individuals on opioids had more pain and worse quality of life.
In March 2022, the CDC proposed doing away with such dosing limits. However, some in the field feel that the limits were actually just cut back from 90 MME to 50 MME. The language, however, is less stringent and leaves more room for patient and clinician best judgement.
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Dose Guidelines for Chronic Pain
Guideline #4 pertains to dosage of opioids for chronic pain states that "clinicians... should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients." Then states with additional specificity, "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. The recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician-patient decision-making."
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Dosing for Acute Pain
Guideline #6 pertaining to the dosing for treatment of acute pain removed the restrictive language about a 3 day maximum. The new guidelines state, "clinicians should prescribe no greater quantity than needed for the expected duration of pain" which is a change from the 2016 guidelines which stated, "Three days or less will often be sufficient; more than seven days will rarely be needed."
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Tapering Medications
The CDC recommended slower, more individualized taper recommendations compared to the 2016 recommendations.
The 2016 recommendations state, "tapers reducing weekly dosage by 10%–50% of the original dosage have been recommended by other clinical guidelines (199), and a rapid taper over 2–3 weeks has been recommended in the case of a severe adverse event such as overdose (30). Experts noted that tapers slower than 10% per week (e.g., 10% per month) also might be appropriate and better tolerated than more rapid tapers, particularly when patients have been taking opioids for longer durations (e.g., for years)."
The new guidelines state:
"Taper durations might need to be adjusted depending on the duration of the initial opioid prescription" and that health care systems "should ensure that policies based on cautionary dosage thresholds do not result in rapid tapers or abrupt discontinuation of opioids, do not penalize clinicians for accepting new patients who are receiving opioids for chronic pain, and do not provide incentives to clinicians to implement rapid tapering."
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