Centers for Disease Control and Prevention (USA) · 2022 edition
Evidence-based recommendations for outpatient opioid prescribing for acute, subacute, and chronic pain in adults
- Issuer
- Centers for Disease Control and Prevention (USA)
- Edition
- 2022 edition
- Audience
- Primary care clinicians, pain medicine specialists, surgeons, emergency medicine physicians, dentists, and all clinicians who prescribe opioids
- Evidence
- GRADE framework; recommendations based on systematic reviews with evidence types 1–4
- Reviewed
- 23 Oct 2026 · GMJ
What this guideline says
GMJ summary
This CDC guideline updates the 2016 opioid prescribing guidance, providing 12 evidence-based recommendations for clinicians prescribing opioids to outpatients aged ≥18 years with acute (duration 3 months) pain. The recommendations exclude pain related to sickle cell disease, cancer, palliative care, and end-of-life care.
The guideline emphasizes that nonopioid therapies are at least as effective as opioids for many common acute pain conditions and are preferred for subacute and chronic pain. When opioids are initiated, clinicians should prescribe immediate-release formulations at the lowest effective dosage for the shortest duration needed. The guideline stresses flexible, person-centered care rather than rigid dose thresholds, explicitly cautioning against misapplication as inflexible standards that could harm patients through abrupt discontinuation or denial of care.
Key risk mitigation strategies include prescribing naloxone, reviewing prescription drug monitoring programs, avoiding concurrent benzodiazepines when possible, and offering evidence-based medication treatment for patients with opioid use disorder. The recommendations are graded using the GRADE framework and reflect systematic reviews of benefits and harms, patient and clinician values, and resource considerations.
Key points
For clinicians — doses and thresholds as stated in the guideline
- For acute pain, prescribe immediate-release opioids at the lowest effective dose (often 5–10 MME per dose, 20–30 MME/day for opioid-naïve patients) for no longer than the expected duration of severe pain
- Do not initiate treatment with extended-release/long-acting (ER/LA) opioids; reserve ER/LA formulations only for severe, continuous pain after at least 1 week of immediate-release opioids at ≥60 mg oral morphine equivalent daily
- Many patients do not benefit from increasing dosage to ≥50 MME/day; carefully reassess individual benefits and risks before any increase beyond this level, using the smallest practical increment
- Evaluate benefits and risks with patients within 1–4 weeks of starting opioid therapy or dosage escalation; regularly reevaluate throughout continuation
- Prescribe naloxone when patient or household member has risk factors for overdose, when dosage is ≥50 MME/day, or when opioids are coprescribed with benzodiazepines
- Review prescription drug monitoring program (PDMP) data when initiating opioids and periodically during chronic therapy to identify high-risk dosages or combinations
- If opioid therapy does not yield benefits outweighing risks, work with patients to gradually taper to lower dosages or discontinue; never abruptly discontinue, especially from higher dosages
- Offer or arrange evidence-based medications (methadone, buprenorphine, naltrexone) for patients with opioid use disorder; detoxification alone is not recommended
Morphine milligram equivalent doses for commonly prescribed opioids
Table extracted from the guideline
| Opioid | Conversion factor |
|---|---|
| Codeine | 0.15 |
| Fentanyl transdermal (mcg/hr) | 2.4 |
| Hydrocodone | 1.0 |
| Hydromorphone | 5.0 |
| Methadone | 4.7 |
| Morphine | 1.0 |
| Oxycodone | 1.5 |
| Oxymorphone | 3.0 |
| Tapentadol | 0.4 |
| Tramadol | 0.2 |
Source: Centers for Disease Control and Prevention (USA), Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. Reproduced in summary form.
What changed in this edition
Versus the previous edition
- Expanded scope from chronic pain only (2016) to include acute and subacute pain management
- Strengthened language discouraging misapplication of dosage thresholds as rigid limits; moved specific MME thresholds from recommendation statements to implementation considerations
- Added explicit warnings against rapid tapering and abrupt discontinuation of opioids, particularly from higher dosages
- Expanded recommendation on naloxone coprescribing and risk mitigation strategies
- Broadened target audience from primary care physicians to all clinicians who prescribe opioids, including dentists, surgeons, and emergency medicine physicians
- Added recommendation on offering evidence-based medications for opioid use disorder as part of pain management
- Incorporated new evidence on comparative effectiveness of opioids versus nonopioid treatments, including a 12-month randomized trial showing nonopioid strategy resulted in similar or better pain outcomes
From the guideline
Verbatim
“Clinicians should avoid abrupt discontinuation of opioids, especially for patients receiving high dosages of opioids, should avoid dismissing patients from care, and should ensure (provide or arrange) appropriate care for patients with pain.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As someone who has advised on health system strengthening in Georgia and the region, I find this guideline's emphasis on multimodal pain management particularly relevant for our context. Georgia's Universal Healthcare Programme since 2013 has improved access to hospital care, but coverage for outpatient physical therapy, psychological interventions, and structured chronic pain management remains limited. The recommendation I would stress most to Georgian clinicians is to establish functional treatment goals and reassess within 1–4 weeks when initiating opioids—this early checkpoint can prevent unintentional long-term prescribing. The realistic caveat for implementation here is that many of the recommended nonopioid therapies (cognitive-behavioral therapy, multidisciplinary pain programmes, extended physical therapy) are not yet widely available or reimbursed outside Tbilisi, creating pressure to rely on medications. We must simultaneously expand access to effective opioid analgesia for patients with severe pain while building the infrastructure for evidence-based nonpharmacologic care, rather than defaulting to either extreme of undertreatment or medication-only approaches.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 23 Oct 2026
Applicability
Georgia and the South Caucasus
Georgia and neighboring South Caucasus countries face dual challenges of undertreated pain and emerging prescription opioid risks. While access to opioid analgesics for severe pain remains limited in the region compared to Western countries, recent increases in opioid availability create opportunities to apply evidence-based prescribing principles from the outset. Georgian national pain management programmes should prioritize expanding access to nonopioid and nonpharmacologic treatments (physiotherapy, cognitive-behavioral therapy, NSAIDs, SNRIs) alongside appropriate opioid availability, establish prescription drug monitoring systems before widespread opioid use, ensure naloxone availability in primary care and community settings, and adapt these recommendations to local formularies and healthcare delivery contexts. Implementation will require training primary care physicians in multimodal pain management, addressing insurance coverage gaps for nonpharmacologic therapies, and balancing appropriate access to opioids for severe pain against prevention of iatrogenic harm as prescription volumes potentially increase.
Questions this guideline answers
Quick answers
When should opioids be considered for acute pain?
Opioids have an important role for severe traumatic injuries (crush injuries, burns), invasive surgeries with moderate to severe postoperative pain, and other severe acute pain when NSAIDs are contraindicated or ineffective. For common acute pain (low back pain, dental pain, kidney stones, minor surgery, musculoskeletal injuries), nonopioid therapies (NSAIDs, acetaminophen, ice, heat) are at least as effective and should be used first.
What is the lowest effective starting dose for opioid-naïve patients?
The lowest starting dose is often equivalent to approximately 5–10 MME per single dose or 20–30 MME/day. For example, hydrocodone 5 mg/acetaminophen 325 mg, one tablet every 4 hours as needed (not around the clock), totaling 20 MME daily if taken four times. Prescribe only the amount needed for the expected duration of severe pain.
At what dosage should I be particularly cautious about increasing opioids?
Use caution at any dosage. Many patients do not experience additional benefit from increasing to ≥50 MME/day but face progressive increases in overdose risk. Before increasing to ≥50 MME/day, pause and carefully reassess individual benefits and risks. Further increases beyond 50 MME/day are progressively more likely to yield diminishing returns in benefits relative to risks. These are guideposts, not rigid thresholds.
What should I do if a patient already on opioids is not achieving treatment goals?
If benefits do not outweigh risks, optimize other therapies (nonpharmacologic and nonopioid pharmacologic) and work closely with the patient to gradually taper to lower dosages or, if warranted, appropriately discontinue opioids. Never abruptly discontinue or rapidly taper, especially from higher dosages, as this can cause serious withdrawal, worsening pain, psychological distress, and increased overdose risk. Tapering should be collaborative and gradual.
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- Issuer
- Centers for Disease Control and Prevention (USA)
- Type
- Guideline
- Edition
- 2022 edition
- Replaces
- CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016
- Status
- Current
- Published
- 2022-11-04
- Languages
- English
- Scope
- Outpatient opioid prescribing for acute, subacute, and chronic pain in adults ≥18 years, excluding sickle cell disease, cancer-related pain, palliative care, and end-of-life care
- Audience
- Primary care clinicians, pain medicine specialists, surgeons, emergency medicine physicians, dentists, and all clinicians who prescribe opioids
- Licence
- Public domain (U.S. Government work)
- Evidence
- GRADE framework; recommendations based on systematic reviews with evidence types 1–4
- Next review
- Not specified
- Record history
- Created 23 Oct 2026 · updated 23 Oct 2026 · next check Apr 2027
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.GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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