Opioid prescribing for chronic pain

CDC2022

Outpatients 18 and older (excludes cancer, sickle cell, palliative, end-of-life). Maximize nonopioid and nonpharmacologic therapy; opioids not first-line for subacute or chronic pain. If used, start immediate-release at lowest effective dose. No hard MME limit, but carefully reassess individual benefits and risks before increasing dosage, with added caution at higher dosages such as 50 MME/day or more. Reevaluate benefits and risks within 1 to 4 weeks of starting or escalating; do not abruptly stop or rapidly taper. Use particular caution with concurrent benzodiazepines; check PDMP; offer naloxone; arrange treatment for opioid use disorder.

VA/DoD2022Grade Strong against / Weak for

Recommends against initiating opioid therapy for chronic non-cancer pain, and against long-term opioid therapy, particularly in younger patients and those with a substance use disorder (strong against). For patients already receiving daily opioids for chronic pain, suggests switching to buprenorphine instead of a full agonist because of lower overdose and misuse risk (weak for). Avoid concurrent benzodiazepines and opioids (strong against).

CDC2022Grade Category B

Patients on long-term opioids: weigh continuing versus tapering. Unless there is a life-threatening issue such as signs of impending overdose, do not stop abruptly or rapidly reduce from higher dosages. After a year or more of use, tapers of about 10% per month or slower are better tolerated; after weeks to months, 10% of the original dose per week or slower until about 30% remains, then about 10% of the remaining dose weekly. Maximize nonopioid treatment; slow or pause the taper for withdrawal.