CDC Opioid Guidelines at 10: Impact, Misuse, and Lessons: Michael Lynch, MD

The CDC’s Clinical Practice Guidelines for Prescribing Opioids for Pain are 10 years old this March. Originally published in 2016 and then updated in 2022, the guidelines aimed to reduce opioid prescription overdoses with suggestions on necessity, dosage, and monitoring.¹

In this interview with The American Journal of Managed Care^®, Michael Lynch, MD, FACMT, an associate professor of emergency medicine at the University of Pittsburgh School of Medicine, discusses the misapplication of the guidelines and their impact on opioid overdose deaths since publication.

This transcript has been lightly edited for clarity.

AJMC: Do you think the guidelines achieved their intended goal of curbing opioid misuse and overdose?

Lynch: I think it would be really hard to say if it's that; a lot of things happened contemporaneously. The guidelines were released; we saw the drug supply nationally transition from one of primarily heroin to one of primarily fentanyl around the same time. And we know that most overdose deaths are related to fentanyl^—illicit fentanyl, not prescription—and meanwhile, overdose deaths related to prescription opioids have been relatively plateaued or slightly decreased since then.

I think there are a lot of hypotheses about what the impact of those guidelines may have been on decreasing access to prescription opioids and whether or not that contributed to increased utilization of illicit opioids with associated dangers. I think it's very hard to link those guidelines specifically to any decreases in prescription opioid overdose–related deaths or, definitively, to increases in illicit opioid overdose deaths. Even though those things were happening around the same time, creating the causal link, I think, is very challenging.

AJMC: Were there any immediate consequences after the 2016 guidelines were published for patients with chronic pain?

Lynch: Absolutely. That was reported fairly broadly amongst individuals in the community, particularly those with chronic pain. I think a lot of that, in my opinion, had to do with application. And I was alluding to this before; those guidelines [were applied] in ways that they weren't necessarily intended to be applied. Guidelines, by their very nature, are intended to be guidance, not rules. And I think both at the state level, in some cases, and among provider and payer levels as well, they were taken more dogmatically than they were meant to be.

They're meant to be guidelines about where risk was and try to, I think, move toward the risk-benefit assessment and were intended—when tapering was potentially indicated—to hopefully do it in a controlled fashion and in collaboration with patients. I think that they were applied in a way that didn't necessarily follow those kinds of standards.

From my perspective, folks were tapered quickly; specific morphine milligram equivalents [MME] per day were thought to be required to be met, and if those weren't met, they were thought to be inappropriate doses and so forth, not by some taking into account historical precedent, like doses people had been on.

Again, I think making it a shared decision-making process, which realistically, the guidelines themselves do talk about, is collaboration with patients. But again, I think they were applied in a way that created confusion and certainly pain for a number of patients.

AJMC: How do clinicians balance opioid risk reduction with effective pain management today?

Lynch: We continue to need a lot of research into ideal pain management strategies, understanding that an individual's pain is not always easy to contextualize into a group of similar people. That's true in medicine in general, but I think with time, what we hope to see is more upfront management and addressing of the underlying contributors to acute and subacute pain as it potentially transitions to chronic pain. Also, trying earlier on, when there's more potential to influence what medications are prescribed and what doses and what additional therapies are provided so we can hopefully mitigate the need for real high doses of opioids that are associated with risks.

For somebody who's already on really high doses, coming off of those is also associated with risk, whether it's depression, suicidality, pain, or illicit drug use. But if we can help folks to find a similar or even improved or better relief of pain without having to be exposed to those risks, particularly over time, I think that is where we hope to see continued improvement.

In my opinion, and what I've seen is improvement where we don't see as many people getting to those very high doses, recognizing that some subset of the population is going to continue to need to be on opioid therapy chronically and potentially even at higher doses. We hope to see that be a smaller subset without sacrificing management of pain and optimizing people's quality of life. That’s sort of my hope of where things have transitioned, whether or not they're specifically because of the guidelines or simply related to a broader awareness of the risks and, frankly, the inadequacy of how we were managing pain.

Fifteen to 20 years ago, leading up to them, I think it was a combination of things, not just the guidelines. I think those have served a purpose, but I also think recognizing that there are better ways to manage pain, and we need to be pulling those as much as we can.

AJMC: How should future frameworks move toward more flexible, individualized approaches that balance safety, patient needs, and public health goals?

Lynch: The keys, or the themes, for me, are oversimplification and unintended consequences. I think we always run the risk of both of those things when we strive to set down sort of black-and-white guidelines. Usually, from a physician or provider group or a health care agency or group perspective, the goal isn't to develop something that's absolutely prescriptive, because health care providers recognize and understand that there is enormous variability amongst individuals, their experiences, their lives, their pain states, and their underlying behavioral and physical health conditions. Despite actually trying to say that and include that in the guidelines, that was the case. These weren't intended to be prescriptive; understanding that once they are there and they're written down, regardless of the intent, they will be taken by some entities and applied in a way that is much more prescriptive than originally intended.

I think recognizing that's the case doesn’t mean that we shouldn't create guidelines because, I think, particularly for very complex systems and issues, and in a world where primary care providers increasingly have reduced time to spend with their patients, having guidelines can be very helpful. I also think balancing the recognition that anything written down in black-and-white can be used in ways that weren't intended and to always recognize whether it's guidelines, laws, regulations, legislation, or unintended consequences that are known, and trying to predict as best you can.

They're unintended for a reason, because we can't predict what those might be, but mitigate them at the outset so that things aren't misapplied. Those would be the takeaways; the science is always going to evolve and change, and that's understood, but really trying to be intentional with the messaging of any guidelines so that they are not meant to be absolute or prescriptive.

Reference

1. McCrear S. The 10th anniversary of the CDC’s opioid prescribing guidelines: new evidence and patient-centered decisions. AJMC. March 24, 2026. Accessed March 25, 2026. https://www.ajmc.com/view/the-10th-anniversary-of-the-cdc-s-opioid-prescribing-guidelines-new-evidence-and-patient-centered-decisions