Journal of Pain & Palliative Care Pharmacotherapy

ISSN: 1536-0288 (Print) 1536-0539 (Online) Journal homepage: http://www.tandfonline.com/loi/ippc20

Guideline for Prescribing Opioids for Chronic Pain

Centers for Disease Control and Prevention, Public Health Service, U.S.
Department of Health and Human Services

To cite this article: Centers for Disease Control and Prevention, Public Health Service,
U.S. Department of Health and Human Services (2016) Guideline for Prescribing Opioids
for Chronic Pain, Journal of Pain & Palliative Care Pharmacotherapy, 30:2, 138-140, DOI:
10.3109/15360288.2016.1173761

To link to this article: http://dx.doi.org/10.3109/15360288.2016.1173761

Published online: 14 Jun 2016.

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Download by: [188.68.3.47] Date: 17 June 2016, At: 18:28

 JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY
, VOL. , NO. , –
http://dx.doi.org/./..

LEGAL AND REGULATORY ISSUES

Guideline for Prescribing Opioids for Chronic Pain

Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services

ABSTRACT KEYWORDS
Improving the way opioids are prescribed through clinical practice guidelines can ensure patients effectiveness; guideline;
have access to safer, more effective chronic pain treatment while reducing the number of people who opioids; prescribing; primary
misuse, abuse, or overdose from these drugs. The Centers for Disease Control and Prevention (CDC) care; safety
developed and published the Guideline for Prescribing Opioids for Chronic Pain to provide recommen-
dations for the prescribing of opioid pain medication for patients 18 and older in primary care set-
tings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than
3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care,
and end-of-life care.
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intended for patients who are in active cancer treat-

Editor’s note:
In response to the high and increasing incidence of opi-
oid deaths in the United States and to calls for interven-
tion by Congress and other national and state legisla-
tive and regulatory bodies, the Centers for Disease Con-
trol and Prevention (CDC) of the U.S. Public Health Ser-
vice promulgated a guideline for primary care practition-
ers on prescribing opioids for chronic pain. The original
draft proposed by the CDC raised serious concerns by
many pain specialists and patient advocacy groups that
it would limit access to needed opioids for patient who
have chronic pain and for whom those medications are
appropriate. The final document was modified somewhat
in response to public comments. The guideline was pub-
lished as a simple two-page document highlighting the
12 points described below.1 A more detailed description
of the rationale for and process by which the guidelines
were developed was published in Morbidity and Mortality
Weekly Reports.2
Improving Practice through Recommendations
CDC’s Guideline for Prescribing Opioids for Chronic
Pain is intended to improve communications between
providers and patients about the risks and benefits of
opioid therapy for chronic pain, improve the safety and
effectiveness of pain treatment, and reduce risks asso-
ciated with long-term opioid therapy, including opi-
oid use disorder and overdose. The guideline is not
ment, palliative care, and end-of-life care.
Determining When to Initiate or Continue Opioids for
Chronic Pain
1. Nonpharmacologic therapy and nonopioid
pharmacologic therapy are preferred for chronic
pain. Clinicians should consider opioid therapy
only if expected benefits for both pain and
function are anticipated to outweigh risks to
the patient. If opioids are used, they should
be combined with nonpharmacologic ther-
apy and nonopioid pharmacologic therapy, as
appropriate.
2. Before starting opioid therapy for chronic pain,
clinicians should establish treatment goals with
all patients, including realistic goals for pain
and function, and should consider how opioid
therapy will be discontinued if benefits do not
outweigh risks. Clinicians should continue opi-
oid therapy only if there is clinically meaning-
ful improvement in pain and function that out-
weighs risks to patient safety.
3. Before starting and periodically during opioid
therapy, clinicians should discuss with patients
known risks and realistic benefits of opioid

CONTACT Centers for Disease Control and Prevention, Public Health Service, U.S. Department of Health and Human Services.
This report was released by the Centers for Disease Control and Prevention on March , . It is in the public domain.

therapy and patient and clinician responsibili-
ties for managing therapy.
Opioid Selection, Dosage, Duration, Follow-up, and
Discontinuation
4. When starting opioid therapy for chronic pain,
clinicians should prescribe immediate-release
opioids instead of extended-release/long-acting
(ER/LA) opioids. When opioids are started,
clinicians should prescribe the lowest effective
dosage. Clinicians should use caution when pre-
scribing opioids at any dosage, should carefully
reassess evidence of individual benefits and risks
when considering increasing dosage to ࣙ50
morphine milligram equivalents (MME)/day,
and should avoid increasing dosage to ࣙ90
MME/day or carefully justify a decision to titrate
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dosage to ࣙ90 MME/day. Long-term opioid
use often begins with treatment of acute pain.
When opioids are used for acute pain, clinicians
should prescribe the lowest effective dose of
immediate-release opioids and should prescribe
no greater quantity than needed for the expected
duration of pain severe enough to require opi-
oids. Three days or less will often be sufficient;
more than 7 days will rarely be needed. Clini-
cians should evaluate benefits and harms with
patients within 1 to 4 weeks of starting opioid
therapy for chronic pain or of dose escalation.
5. Clinicians should evaluate benefits and harms of
continued therapy with patients every 3 months
or more frequently. If benefits do not outweigh
harms of continued opioid therapy, clinicians
should optimize other therapies and work with
patients to taper opioids to lower dosages or to
taper and discontinue opioids.
6. Before starting and periodically during contin-
uation of opioid therapy, clinicians should eval-
uate risk factors for opioid-related harms. Clin-
icians should incorporate into the management
plan strategies to mitigate risk, including con-
sidering offering naloxone when factors that
increase risk for opioid overdose, such as his-
tory of overdose, history of substance use dis-
order, higher opioid dosages (ࣙ50 MME/day),
or concurrent benzodiazepine use, are present.
Clinicians should review the patient’s history of
controlled substance prescriptions using state
prescription drug monitoring program (PDMP)
JOURNAL OF PAIN & PALLIATIVE CARE PHARMACOTHERAPY 139
data to determine whether the patient is receiv-
ing opioid dosages or dangerous combinations
that put him or her at high risk for overdose.
Clinicians should review PDMP data when
starting opioid therapy for chronic pain and
periodically during opioid therapy for chronic
pain, ranging from every prescription to every
3 months. When prescribing opioids for chronic
pain, clinicians should use urine drug test-
ing before starting opioid therapy and con-
sider urine drug testing at least annually to
assess for prescribed medications as well as
other controlled prescription drugs and illicit
drugs.
7. Clinicians should avoid prescribing opioid pain
medication and benzodiazepines concurrently
whenever possible. Clinicians should offer or
arrange evidence-based treatment (usually
medication assisted treatment with buprenor-
phine or methadone in combination with be-
havioral therapies) for patients with opioid use
disorder.
Assessing Risk and Addressing Harms of Opioid use
8. Before starting and periodically during contin-
uation of opioid therapy, clinicians should eval-
uate risk factors for opioid-related harms. Clin-
icians should incorporate into the management
plan strategies to mitigate risk, including con-
sidering offering naloxone when factors that
increase risk for opioid overdose, such as history
of overdose, history of substance use disorder,
higher opioid dosages (ࣙ50 MME/day), or con-
current benzodiazepine use, are present.
9. Clinicians should review the patient’s history of
controlled substance prescriptions using state
prescription drug monitoring program (PDMP)
data to determine whether the patient is receiv-
ing opioid dosages or dangerous combinations
that put him or her at high risk for overdose.
Clinicians should review PDMP data when
starting opioid therapy for chronic pain and
periodically during opioid therapy for chronic
pain, ranging from every prescription to every
3 months.
10. When prescribing opioids for chronic pain, clin-
icians should use urine drug testing before start-
ing opioid therapy and consider urine drug test-
ing at least annually to assess for prescribed
 140 CENTERS FOR DISEASE CONTROL & PREVENTION, ET AL.
medications as well as other controlled prescrip-
tion drugs and illicit drugs.
11. Clinicians should avoid prescribing opioid pain
medication and benzodiazepines concurrently
whenever possible.
12. Clinicians should offer or arrange evidence-
based treatment (usually medication assisted
treatment with buprenorphine or methadone
in combination with behavioral therapies) for
patients with opioid use disorder.
Clinical Reminders
• Opioids are not first-line or routine therapy for
chronic pain
• Establish and measure goals for pain and function
• Discuss benefits and risks and availability of nono-
pioid therapies with patient
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• Use immediate-release opioids when starting
• Start low and go slow
• When opioids are needed for acute pain, prescribe
no more than needed
• Do not prescribe ER/LA opioids for acute pain
• Follow-up and reevaluate risk of harm; reduce
dose or taper and discontinue if needed
• Evaluate risk factors for opioid-related harms
• Check PDMP for high dosages and prescriptions
from other providers
• Use urine drug testing to identify prescribed sub-
stances and undisclosed use
• Avoid concurrent benzodiazepine and opioid pre-
scribing
• Arrange treatment for opioid use disorder if
needed
To learn more, see: www.cdc.gov/drug overdose/
prescribing/guideline.html.
References
1. http://www.cdc.gov/drugoverdose/pdf/guideline_factsheet-
a.pdf.
2. Dowell D, Haegerich TM, Chou R. CDC Guideline for
Prescribing Opioids for Chronic Pain—United States,
2016. MMWR Recomm Rep. 2016;65:1–49. Also posted
as an MMWR Early Release on the MMWR Web site
(http://www.cdc.gov/mmwr).