The 10th Anniversary of the CDC's Opioid Prescribing Guidelines: New Evidence and Patient-Centered Decisions

This March marks the 10th anniversary of the CDC’s Clinical Practice Guideline for Prescribing Opioids for Pain, originally published in 2016 and updated in 2022.

The guidelines provided recommendations for clinicians providing pain care for adults and aimed to address the long-standing opioid epidemic in the US.¹ The guidelines serve as recommendations guiding clinicians to make the best patient-centered decision that caters to an individual’s care needs. The original guidelines published in 2016 stirred tension among physicians as the recommendations were fairly narrow and restrictive.² However, the updated version broadened the patient population from those with chronic pain specific to noncancer, nonpalliative, and non–end-of-life care settings to all adults with pain in an outpatient setting.^1,3 Recommendations regarding the dosage, durations, tapering, and discontinuation, among other factors, were also broadened in the 2022 update. However, despite the latitude of the 2022 updated guidelines, overall deaths from opioid overdoses in 2023 are nearly 10 times those in 1999. Yet, the rate of overdose deaths from prescription opioids decreased by approximately 12% from 2022 to 2023, since the update.³

“I think the guidelines also put us in a position to better understand monitoring of those medications,” Jim Lichauer, PharmD, BCPS, FASHP, senior performance improvement program director of pharmacy at Vizient, said in an interview with The American Journal of Managed Care^®. “And there was a lot put in place to help improve that monitoring and infrastructure around appropriate pain management and then opiate overdose deaths for prescription opiates.”

Initially, after the guidelines were published in 2016, there was no immediate decrease in prescription opioid deaths, Kerry Schwarz, PharmD, MPH, senior clinical manager of evidence-based medicine at Vizient, said in an interview with AJMC®, despite the sharp decline in opioid prescriptions issued by primary care physicians.

“This is thought to be driven by illicit opioid use, and this is one of the reasons behind the guideline update in 2022, we started to see this emerge,” she said.

The 2016 Guidelines vs the 2022 Update

In response to the 2016 guidelines, numerous states implemented their own guidance, many of which included “dose-based limits” or mandated that physicians drastically taper the dosage of patients on long-term opioids to specific thresholds. But these mandates were not explicitly stated in the CDC guidelines.²

“I think when these guidelines came into place, sometimes it was more of a little bit more of a misapplication of overreaching with the guidelines, putting in hard limits when maybe we shouldn’t have,” Lichauer said.

Disparities in prescribing patterns were evident; Alabama had an opioid prescribing rate 2.7 times that of the lowest prescribing state, Hawaii.¹ Since then, Alabama has implemented its own guidance loosely based on the CDC’s guidelines with no single hard maximum dosage but rather a tiered system of recommended dosages in tandem with monitoring and documentation.⁴

Nevertheless, the initial impact of the guidelines created barriers for physicians and vulnerable populations. Before the 2022 update, numerous physicians challenged the guidelines with reports of “iatrogenic tapering harms.”² One of them was Beth Darnall, PhD, an associate professor in the Department of Anesthesiology, Perioperative, and Pain Medicine at Stanford University School of Medicine, and director of the Stanford Pain Relief Innovations Lab.

In her rebuttal of the 2016 guidelines, Darnall wrote that the recommendations were “rigid” and that they “violate the basic principles of patient-centered pain care” and “undermine” physicians’ ability to make evidence-based decisions in the interest of their patients. ² Thus, the update explicitly emphasizes that the guidelines “provide recommendations only” and that they do not replace physicians’ clinical judgment and “individualized, patient-centered decision-making.”⁵

The 2022 guidelines include 12 recommendations for clinicians providing pain care for outpatient adults that encompass a broad array of considerations, ranging from necessity to risk and potential harm. The 12 recommendations are further categorized into 4 areas: determining whether or not to initiate opioids for pain; selecting opioids and determining dosages; deciding the duration of initial opioid prescription and conducting follow-up; and assessing risk and addressing potential harms of opioid use.⁶

One of the most significant shifts between the 2016 and 2022 guidelines was the emphasis on shared decision-making, Schwarz said.

“That foundational relationship between the clinician and the patient and assessments are very valuable,” she said. “And used today, [it allows physicians] to identify patients with risk factors for both adverse outcomes and opioid misuse, abuse, and dependence, as well as identifying patients that will derive the most benefit from appropriate opioid analgesics.”

How Were Patients Impacted?

The most recent guidelines suggest specific thresholds for standard patients and opioid-naive patients with acute, subacute, or chronic pain. For opioid-naive patients, the guidelines suggest starting with the lowest possible dose. And for those already receiving opioids, physicians should “carefully weigh benefits and risks” when altering dosage.⁶

“Those were thresholds based on risk of opiate overdose, especially over 90 [morphine milligram equivalents]; then the risk of opiate overdose went up,” Lichauer said. “And the misapplication of that, using those as hard limits, probably did hinder many physicians and/or impact patients.”

Initially, physicians faced barriers regarding a lack of infrastructure for sufficient monitoring of patients on opioids, Lichauer said. However, over time, health systems developed integrated pain teams to expand patient access to nonpharmacological therapy. Ultimately, the goal of the guidelines was to encourage physicians and pharmacists to consider alternatives to opioids for pain management, as studies have shown they are not the most “effective” therapy.^2,6

“I think in the end, it gave us an opportunity to really evaluate care as a whole,” Lichauer said. “And I think overall, at this point, we're in better shape, providing care for both acute and chronic pain because of this and several of the other actions around that time.”

The guidelines were updated on the basis of new evidence, which is consistently evolving and will continue to influence and direct future policies and guidelines to best address the current opioid epidemic and the needs of patients.

“Part of the evidence that was included in the 2022 update was evidence looking at application or misapplication of the 2016 guidelines,” Schwarz said. “I think these are steps towards approaches that are more individualized while still being evidence and experience-based.”

References

1. Mattina C, Joszt L. Opioid guideline: prescribing for pain management and use in the emergency department. AJMC^®. December 11, 2016. Accessed March 23, 2026. https://www.ajmc.com/view/prescribing-opioids-for-pain-management-and-use-of-opioids-in-the-emergency-department

2. Darnall B. The 2016 CDC opioid prescribing guideline for chronic pain: unintended consequences and a revision on the Horizon. ASRA Pain Medicine. February 1, 2021. Accessed March 23, 2026. https://asra.com/news-publications/asra-newsletter/newsletter-item/asra-news/2021/02/01/the-2016-cdc-opioid-prescribing-guideline-for-chronic-pain-unintended-consequences-and-a-revision-on-the-horizon

3. Understanding the opioid overdose epidemic. CDC. June 9, 2025. Accessed March 23, 2026. https://www.cdc.gov/overdose-prevention/about/understanding-the-opioid-overdose-epidemic.html

4. Prescribing. Alabama Board of Medical Examiners & Medical Licensure Commission. Accessed March 23, 2026. https://www.albme.gov/resources/licensees/prescribing-issues/

5. 2022 CDC clinical practice guideline at a glance. CDC. May 7, 2024. Accessed March 23, 2026. https://www.cdc.gov/overdose-prevention/hcp/clinical-guidance/index.html

6. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain — United States, 2022. MMWR Recomm Rep. 2022;71(No. RR‑3):1‑95. doi:10.15585/mmwr.rr7103a1