CDC Clinical Practice Guideline for Prescribing Opioids for Pain<b>—</b>United States, 2022

This document is a clinical practice guideline, not a single experimental study. It represents a systematic review and synthesis of a vast body of scientific evidence related to the effectiveness and risks of prescribing opioids for various types of pain. The "intervention" being evaluated, in essence, is the *practice of opioid prescribing* itself, and how different approaches to it impact patient outcomes.

The guideline aims to provide recommendations for clinicians on:

1. **Determining whether or not to initiate opioids for pain:** This involves assessing the suitability of opioids versus non-opioid treatments for acute, subacute, and chronic pain.

2. **Selecting opioids and determining opioid dosages:** This covers choices of specific opioid medications and appropriate dosing strategies.

3. **Deciding duration of initial opioid prescription and conducting follow-up:** This focuses on how long opioids should be prescribed initially and the importance of ongoing monitoring.

4. **Assessing risk and addressing potential harms of opioid use:** This includes strategies for identifying and mitigating risks like opioid use disorder, overdose, and other adverse effects.

The "comparators" are broadly existing clinical practices, previous guidelines (specifically the 2016 CDC Guideline), and the outcomes associated with different pain management approaches (opioid-centric vs. non-opioid-centric).

The "outcome measures" considered in the underlying evidence reviews, which informed these recommendations, include:

**Pain intensity:** How much pain a person experiences.

**Pain-related function:** A person's ability to perform daily activities, work, and engage in social roles despite pain.

**Quality of life:** Overall well-being and satisfaction with life.

**Adverse events:** Side effects of opioid therapy, including nausea, constipation, sedation, and more serious harms like opioid use disorder (OUD), overdose, and death.

**Patient satisfaction:** How satisfied patients are with their pain treatment.

For a self-experimenter, understanding these areas helps frame discussions with healthcare providers and informs personal choices about pain management, particularly regarding the role of opioids.

As a guideline, this document does not involve a "sample" of individuals in the traditional sense of a research study. Instead, it synthesizes evidence from numerous studies that collectively involved potentially hundreds of thousands, if not millions, of patients.

The recommendations within the guideline are intended for **outpatients aged 18 years or older** who are experiencing:

**Acute pain:** Pain lasting less than 1 month.

**Subacute pain:** Pain lasting between 1 and 3 months.

**Chronic pain:** Pain lasting more than 3 months.

The guideline explicitly states that its recommendations **do not apply** to:

Pain related to sickle cell disease.

Pain related to cancer.

Patients receiving palliative care.

Patients receiving end-of-life care.

The underlying evidence base would have included studies conducted in various outpatient settings across the United States and potentially internationally, encompassing a wide range of demographic characteristics, pain conditions (e.g., back pain, osteoarthritis, neuropathic pain), and comorbidities. The guideline also acknowledges and discusses significant health disparities in pain treatment, noting that certain populations (e.g., Black, Hispanic, and Asian patients, women, older persons, those with cognitive impairment or mental/substance use disorders) are at risk for inadequate pain treatment or disproportionate application of safeguards.

Since this is a guideline based on a systematic review, the "measurement" process refers to how the evidence was identified, evaluated, and synthesized to formulate recommendations. The CDC developed this guideline using the **Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework**.

The GRADE framework is a structured, transparent approach used to:

1. **Formulate clinical questions:** Specific questions about opioid prescribing were developed (e.g., "For adults with acute pain, what are the benefits and harms of opioid therapy compared with nonopioid therapy?").

2. **Conduct systematic reviews of evidence:** Researchers systematically searched for and reviewed existing scientific literature (randomized controlled trials, observational studies, etc.) that addressed these clinical questions. This involved:

* **Identifying relevant studies:** Comprehensive searches of databases like MEDLINE, Embase, and Cochrane Library.

* **Extracting data:** Information on interventions, comparators, outcomes (pain, function, quality of life, adverse events), and study characteristics was extracted.

* **Assessing risk of bias:** Each study was evaluated for methodological quality and potential biases (e.g., selection bias, performance bias, detection bias, attrition bias, reporting bias).

3. **Rate the certainty of evidence:** For each outcome, the overall body of evidence was rated for its certainty (or quality) as high, moderate, low, or very low. This rating considers factors like:

* **Study design:** Randomized controlled trials generally start as high certainty, while observational studies start as low.

* **Risk of bias:** Serious limitations in study design or execution can downgrade certainty.

* **Inconsistency:** Wide variation in results across studies can downgrade certainty.

* **Indirectness:** Evidence from populations, interventions, comparators, or outcomes different from those of interest can downgrade certainty.

* **Imprecision:** Few events or wide confidence intervals can downgrade certainty.

* **Publication bias:** Evidence of selective reporting of positive results can downgrade certainty.

* **Magnitude of effect:** Very large effects can upgrade certainty.

* **Dose-response gradient:** A clear relationship between dose and effect can upgrade certainty.

* **Confounding:** Plausible residual confounding that would reduce a demonstrated effect can downgrade certainty.

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