CDC’s 2022 pain management guidelines are ‘better,’ but opioids should be ‘last resort’

Key takeaways:

• The CDC’s 2022 guidelines improved upon the agency’s 2016 recommendations, which were criticized for lacking scientific data.
• Still, an expert noted that nonopioid treatment should take a greater role in pain management.

ORLANDO — The CDC’s updated guidance on prescription opioids in 2022 were a step in the right direction, but nonopioid therapies should take a more “prominent role” in the management of pain, according to a speaker.

J. Mark Bailey, DO, PhD, FACN, a professor of neurology and anesthesiology at the University of Alabama at Birmingham, explained that the 2016 CDC guidelines for opioid prescriptions were “broad suggestions on how to handle pain” in “an effort to help us out.”

At that time, it was recommended that clinicians avoid or justify increasing daily opioid dosage to 90 morphine milligram equivalents (MME) or higher and use urine testing before opioid therapy. The guidelines were intended specifically for primary care providers.

However, the guidance was based on “weak data ... almost to the level of expert opinion and not science,” Bailey explained.

Despite significant backlash from leading medical organizations, the guidance remained unchanged after public comment and resulted in its misapplication in multiple patient populations, and people experienced adverse health outcomes from sudden tapering or discontinuation of medications.

“When you go from [400 to 90 MME a day] ... it was fierce,” Bailey recalled. “There were a lot of suicides in that group. It was not the right call.”

He added that dosage limitations were also misapplied in the treatment of patients in end-of-life care.

“This in no way should have been applied to those populations,” Bailey said.

These negative repercussions were eventually addressed in 2022, when the CDC updated its recommendations. Bailey pointed out that the new guidelines:

• removed the arbitrary dosage ceiling;
• applied to additional clinicians like nurse practitioners and physician assistants;
• called for improved payment of multimodal treatments;
• are less strict about drug screening (although Baily says it should still be done);
• promoted integrated pain management and joint decision-making; and
• were explicitly voluntary.

Ultimately, “they’re better,” Bailey noted.

Still, he said future guidelines should give more weight to alternative approaches to pain management, like cognitive behavioral therapy, for example.

Furthermore, although the updated guidelines were an improvement, “more and more, opioids are going to have to be viewed as a treatment of last resort,” Bailey explained.

As a result, nonopioid treatments should take a greater role in chronic pain management.

“The current feeling is that when you have a patient walk into your office with low back pain, the correct thing is to not pick up the script pad at all [and to] consider lifestyle changes, yoga classes, tai chi classes, water aerobics... but not medicine,” Bailey said. “That’s such a very different way of thinking than we do right now."