Guideline Recommendations and Guiding Principles

2022 Clinical Practice Guideline recommendations

The 12 recommendations are grouped into four areas of consideration.

• Determining whether or not to initiate opioids for pain (Recommendations 1, 2)
• Selecting opioids and determining opioid dosages (Recommendations 3, 4, 5)
• Deciding duration of initial opioid prescription and conducting follow-up (Recommendations 6, 7)
• Assessing risk and addressing potential harms of opioid use (Recommendations 8, 9, 10, 11, 12)

Guiding principles for implementing recommendations

These five guiding principles should broadly inform the implementation of the 2022 Clinical Practice Guideline recommendations.

1. Acute, subacute, and chronic pain needs to be appropriately assessed and treated independent of whether opioids are part of a treatment regimen.

2. Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount.

3. A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.A

4. Special attention should be given to avoid misapplying this clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended and potentially harmful consequences for patients.

5. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities; provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities; and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons.

Determining whether or not to initiate opioids for pain

All patients with pain should receive treatment that provides the greatest benefits relative to risks.

Recommendations 1 and 2 address determining whether or not to initiate opioids for pain.

Recommendation 1

Nonopioid therapies are at least as effective as opioids for many common types of acute pain.

Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider opioid therapy for acute pain if benefits are anticipated to outweigh risks to the patient.

Before prescribing opioid therapy for acute pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy.

Nonopioid therapies include:

• Nonopioid medications such as acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and selected antidepressants and anticonvulsants

• Nonpharmacologic therapies such as ice, heat, elevation, rest, immobilization, or exercise as appropriate for the specific condition

Recommendation 2

Nonopioid therapies are preferred for subacute and chronic pain. Clinicians should maximize use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition and patient and only consider initiating opioid therapy if expected benefits for pain and function are anticipated to outweigh risks to the patient.

Before starting opioid therapy for subacute or chronic pain, clinicians should discuss with patients the realistic benefits and known risks of opioid therapy, should work with patients to establish treatment goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks.

Selecting opioids and determining opioid dosages

The appropriate selection of opioids and dosage are important factors when opioid therapy is prescribed as part of a patient's pain management plan. Recommendations 3-5 address opioid selection and dosage.

Recommendation 3

When starting opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release and long-acting (ER/LA) opioids.

Recommendation 4

When opioids are initiated for opioid-naïve patients with acute, subacute, or chronic pain, clinicians should prescribe the lowest effective dosage.

If opioids are continued for subacute or chronic pain, clinicians should use caution when prescribing opioids at any dosage, should carefully evaluate individual benefits and risks when considering increasing dosage, and should avoid increasing dosage above levels likely to yield diminishing returns in benefits relative to risks to patients.B

Recommendation 5

For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage.

• If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy.
• If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids.

Unless there are indications of a life-threatening issue such as warning signs of impending overdose (e.g., confusion, sedation, or slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages.

Deciding duration of initial opioid prescription and conducting follow-up

Recommendations 6 and 7 address the duration of opioid therapy and routine patient follow-up.

Recommendation 6

When opioids are needed for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids.

Recommendation 7

Clinicians should evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy for subacute or chronic pain or of dosage escalation. Clinicians should regularly reevaluate benefits and risks of continued opioid therapy with patients.

Assessing risk and addressing potential harms of opioid use

Assessing risk and addressing potential harms of opioid use are addressed by recommendations 8, 9, 10, 11, 12.

Recommendation 8

Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk for opioid-related harms and discuss risk with patients.

Clinicians should work with patients to incorporate into the management plan strategies to mitigate risk, including offering naloxone.

Recommendation 9

When prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, 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 receiving opioid dosages or combinations that put the patient at high risk for overdose.

Recommendation 10

When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances.

Recommendation 11

Clinicians should use particular caution when prescribing opioid pain medication and benzodiazepines concurrently and consider whether benefits outweigh risks of concurrent prescribing of opioids and other central nervous system depressants.

Recommendation 12

Clinicians should offer or arrange treatment with evidence-based medications to treat patients with opioid use disorder.

Detoxification on its own, without medications for opioid use disorder, is not recommended for opioid use disorder because of increased risks for resuming drug use, overdose, and overdose death.

FDA-approved medications indicated for the treatment of opioid use disorder include buprenorphine, methadone, and naltrexone. Buprenorphine can be prescribed by any clinician with a current, standard DEA registration with Schedule III authority, in any clinical setting. Information about qualifications and the process to prescribe buprenorphine are available from the Substance Abuse and Mental Health Services Administration. Methadone used to treat those with a confirmed diagnosis of opioid use disorder (OUD) can only be dispensed through a SAMHSA certified OTP. Naltrexone can be prescribed and administered by any practitioner licensed to prescribe medications.