• Clinical Practice Guideline

    Opioid Prescribing for Chronic Pain

    (Reaffirmation of Value, July 2021)

    The CDC Guideline for Prescribing Opioids for Chronic Pain, was developed by the Centers for Disease Control and Prevention and was reviewed and categorized as Affirmation of Value by the American Academy of Family Physicians.

    Key Recommendations

    • Nonpharmacologic and nonopioid pharmacologic therapies are preferred for chronic pain. Opioid therapy should be considered only when benefits for both pain and function are anticipated to outweigh the risks. If opioids are used, they should be combined with nonpharmacologic and nonopioid pharmacologic therapy as appropriate.
    • Realistic treatment goals for pain and function should be established before initiation of opioid therapy. Opioid treatment should be continued only if there is meaningful improvement in pain and function that outweighs risk.
    • When starting opioid therapy for chronic pain, the lowest effective dose of immediate-release opioids should be prescribed instead of extended-release/long-active (ER/LA) opioids.
    • Benefits and risks should be reassessed when increasing dosages to ≥50 morphine milligram equivalents (MME)/day. Dosages ≥90 MME/day should be carefully justified or avoided if possible.
    • For acute pain, the lowest effective dose of immediate-release opioids should be prescribed in no greater quantity than is needed for severe pain.
    • Benefits and harms should be evaluated with patients within one to four weeks of initiating or escalating dose of opioids for chronic pain and at least every three months thereafter. If benefits do not outweigh the harms, a plan to taper opioids and optimize other therapies should be developed.
    • Risk factors for opioid-related harms should be evaluated prior to initiation and periodically during treatment. Strategies to mitigate risk should be developed, including offering naloxone to those at increased risk for overdose.
    • A patient’s history of controlled substance prescriptions using a prescription drug monitoring program (PDMP). PDMP data should be reviewed when starting opioid therapy and periodically during treatment.
    • Urine drug testing may be used prior to initiating opioid therapy and periodically during treatment to asses for controlled prescription medications as well as illicit drugs.
    • Co-prescription of opioids and benzodiazepines should be avoided whenever possible.
    • Evidence-based treatment including medication-assisted treatment with buprenorphine or methadone and behavioral therapies should be offered to patients with opioid use disorder.

    See the full recommendation for additional details.

    The AAFP uses the category of “Affirmation of Value” to support clinical practice guidelines that provide valuable guidance, but do not meet our criteria for full endorsement. The primary reasons for not endorsing this guideline included:

    • Strong (category A) recommendations were made based on limited or insufficient evidence. None of the recommendations are based on high quality evidence.
    • Due to the poor evidence base, the recommendations are generally consensus and therefore are “good practice points” rather than category A recommendations.
    • The methodology included inconsistent inclusion and exclusion criteria.

    These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented.