CDC's 2022 opioid prescribing guideline: what it says about the extraction patient, and what it says it is not

What it says#

The CDC Clinical Practice Guideline for Prescribing Opioids for Pain gives recommendations for clinicians providing pain care, including those prescribing opioids, to outpatients aged 18 and older with acute pain (duration under one month), subacute pain (one to three months) or chronic pain (more than three months). It does not apply to pain from sickle cell disease or cancer, or to palliative or end-of-life care. It covers four questions: whether to start opioids at all, which opioid and what dose, how long an initial prescription should run and how to follow up, and how to assess and reduce risk. There are twelve recommendations, each graded on the GRADE framework as adapted for CDC advisory work: category A applies to all persons and most patients should receive the recommended course, category B calls for individual decision-making; evidence types run from 1, randomized trials or overwhelming observational evidence, to 4, clinical experience or studies with important limitations. The document states in its introduction that its recommendations are voluntary and are not to be used as inflexible standards of care.

Recommendation 1 (category B, evidence type 3) is the one that reaches a dental office most days: nonopioid therapies are at least as effective as opioids for many common types of acute pain, and clinicians should maximize nonpharmacologic and nonopioid pharmacologic therapy and consider an opioid only if the benefits are anticipated to outweigh the risks, after discussing both with the patient. The implementation notes name the conditions: among them, pain from minor surgeries typically associated with minimal tissue injury and mild postoperative pain, with simple dental extraction as the example, and dental pain generally. The evidence review found opioids were probably less effective than NSAIDs for surgical dental pain. The guideline cites the American Dental Association's recommendation of NSAIDs as first-line treatment for acute dental pain and says that, when not contraindicated, NSAIDs should be used for dental pain and postoperative pain, weighing the gastrointestinal and cardiovascular risks of NSAIDs in patients with those comorbidities. Opioids retain a role for severe traumatic injuries, invasive surgeries typically associated with moderate to severe postoperative pain, and other severe acute pain when NSAIDs and other therapies are contraindicated or likely to be ineffective.

When an opioid is warranted, three recommendations set its shape. Recommendation 3 (A, type 4): immediate-release products rather than extended-release or long-acting ones. Recommendation 4 (A, type 3): the lowest effective dosage for an opioid-naive patient, which the notes say is often a single dose of approximately 5 to 10 morphine milligram equivalents, or 20 to 30 MME per day. Recommendation 6 (A, type 4): no greater quantity than needed for the expected duration of pain severe enough to require opioids. The notes add that for many common causes of nontraumatic, nonsurgical pain a few days or less are often sufficient; that since 2017 multiple studies have found many patients do not use all the opioids prescribed after surgery, one study finding a median consumption of three 5 mg oxycodone tablets or less after five common procedures; and that some patients nevertheless needed opioids for up to 15 days. The guideline's worked example of an as-needed prescription is hydrocodone 5 mg with acetaminophen 325 mg, one tablet not more often than every four hours as needed, rather than on a schedule. If a patient continues on opioids for acute pain they should be evaluated at least every two weeks, and if opioids were taken around the clock for more than a few days, a brief taper is prescribed rather than an abrupt stop.

The risk recommendations apply from the first prescription. Recommendation 8 (A, type 4): before starting and periodically during opioid therapy, evaluate the risk of opioid-related harms, discuss it with the patient, and build mitigation into the plan, including offering naloxone. Recommendation 9 (B, type 4): when prescribing initial opioid therapy for acute, subacute or chronic pain, review the patient's controlled substance history in the state prescription drug monitoring program to see whether the patient is receiving dosages or combinations that put them at high risk of overdose; the notes caution that PDMP data has been used to dismiss patients from practices, which may leave pain untreated. Recommendation 11 (B, type 3): particular caution when opioids and benzodiazepines are prescribed together. Recommendation 12 (A, type 1): offer or arrange medication treatment for a patient found to have opioid use disorder.

What the guideline is not takes up as much of the front matter as what it is. It is not a replacement for clinical judgment; not to be applied as inflexible standards of care by health professionals, health systems, pharmacies, payers or governments, nor to lead to rapid tapering or abrupt discontinuation; and not a law, regulation or policy that dictates practice, nor a substitute for FDA-approved labeling. Its closing section lists the misapplications it wants to avoid: being inflexible on dosage and duration, discontinuing or dismissing patients from a practice, rapidly tapering stable patients, and applying the recommendations to populations it excludes.

Who it applies to#

The 2016 guideline was written for primary care clinicians treating chronic pain. This one names its wider audience and explains why: primary care writes about 37 percent of opioid prescriptions, pain medicine 8.9 percent and dentists 8.6 percent, so the recommendations are addressed to every clinician who prescribes for pain, and the workgroup that reviewed the draft included a dentistry perspective. For a dental practice the operative categories are acute pain, which is the extraction, the pulpitis and the surgical patient, and, rarely, subacute pain that has not resolved after a month, at which point the guideline says continuing opioids is a deliberate decision to begin long-term therapy, not a refill.

It is written for adults; patients under 18 are outside its scope, as are inpatients. It excludes sickle cell disease, cancer-related pain, palliative and end-of-life care, and opioids prescribed for opioid use disorder. And because it is voluntary, the rules that actually bind a prescriber are elsewhere: the guideline itself notes that some laws, regulations and policies built on its 2016 predecessor went beyond what that document said. Your state's prescribing limits and PDMP mandate are separate documents, and this entry does not summarize them.

What changed#

Compared with the 2016 guideline, three things. The scope grew from chronic pain in primary care to acute, subacute and chronic pain for all clinicians, after five new systematic reviews commissioned from the Agency for Healthcare Research and Quality affirmed the 2016 recommendations on chronic pain and prompted CDC to address acute and subacute pain explicitly. The language on dose was rewritten: to discourage the misapplication of dosage thresholds as inflexible standards, the recommendation statements now emphasize principles such as avoiding increases above levels likely to yield diminishing returns, rather than reading as ceilings. And the document is explicit, repeatedly, about how it is not to be used, a response to what CDC describes as misapplication of the 2016 guideline by health systems, payers and governments.

For a dentist the substantive position did not soften. NSAIDs first for dental pain, an opioid only where benefits outweigh risks, immediate-release at the lowest effective dose for the expected duration of severe pain, a PDMP check before the first prescription, and naloxone where the risk warrants it, are all in the 2022 text with category A behind most of them.

Where the source is#

The guideline is published in MMWR Recommendations and Reports, volume 71, number RR-3, on cdc.gov, with a PDF of the full 95-page document. CDC's site refuses automated readers, so the full text for this entry was read from the same article as deposited in PubMed Central (PMC9639433), which carries the identical text under a CC0 public-domain license; the cdc.gov pages were confirmed to load separately. CDC's guideline-at-a-glance page for clinicians links the MMWR page. The 2016 guideline it replaced is MMWR Recomm Rep 2016;65(No. RR-1). All of it is public and free to copy.