CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

Dowell, Deborah; Haegerich, Tamara M.; Chou, Roger

doi:10.1001/jama.2016.1464

Cited by 5,161Opioid Use Disorder TreatmentPain Management and Opioid UseAnesthesia and Pain Management

CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

Open access

Dowell, Deborah, Haegerich, Tamara M., Chou, Roger·2016·JAMA

DOI 10.1001/jama.2016.1464PMC PMC6390846

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Abstract

IMPORTANCE: Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. OBJECTIVE: To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. PROCESS: The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. EVIDENCE SYNTHESIS: Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. RECOMMENDATIONS: There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. CONCLUSIONS AND RELEVANCE: The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.

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Crossref · 10.1001/jama.2016.1464

Cites

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Statistics

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Claims the paper makes

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Finding
The guideline says nonopioid therapy is preferred for chronic pain and opioids should be used only when expected benefits outweigh risks.
“Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks.”
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Finding
When opioids are used, clinicians should prescribe the lowest effective dosage and carefully reassess benefits and risks when considering doses of 50 morphine milligram equivalents or more per day.
“When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day,”
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Finding
Nonpharmacologic and nonopioid pharmacologic treatments were found to be effective for chronic pain in studies lasting 2 weeks to 6 months.
“Several nonpharmacologic and nonopioid pharmacologic treatments were found to be effective for chronic pain in studies ranging in duration from 2 weeks to 6 months48–66 (Table 3).”
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Finding
No study evaluated long-term benefit of opioids for chronic pain.
“No study evaluated long-term (≥1 year) benefit of opioids for chronic pain.”
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Finding
The recommendations are voluntary rather than prescriptive standards and are based on emerging evidence with notable limitations.
“The recommendations in the guideline are voluntary, rather than prescriptive standards. They are based on emerging evidence, including observational studies or randomized clinical trials with notable limitations.”
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Finding
Opioid therapy prescribed for acute pain was associated with greater likelihood of long-term use in studies of low-risk surgery and low back pain from injury.
“Studies examining patients who underwent low-risk surgery or experienced low back pain from injury revealed that opioid therapy prescribed for acute pain was associated with greater likelihood of long-term use.”
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Finding
No study evaluated the effectiveness of risk mitigation strategies.
“No study evaluated the effectiveness of risk mitigation strategies.”
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Finding
The evidence base consisted of low-quality observational studies or randomized trials with important limitations.
“Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology.”
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Finding
Opioids were associated with increased risks including opioid use disorder, overdose, and death, with dose-dependent effects.
“Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent affects.”
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Finding
Before starting opioids, clinicians should establish treatment goals and consider how opioids will be discontinued if benefits do not outweigh risks.
“Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks.”
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Finding
The updated review found insufficient evidence to determine long-term benefits of opioid therapy for chronic pain, although serious harms appear dose-dependent.
“The updated review revealed that evidence on long-term opioid therapy for chronic pain outside of end-of-life care remains limited, with insufficient evidence to determine long-term benefits, although evidence suggests risk of serious harms that is dose-dependent.”
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Finding
No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy evaluated long-term outcomes for pain, function, or quality of life.
“No study of opioid therapy vs placebo, no opioid therapy, or non-opioid therapy for chronic pain evaluated long-term (≥1 year) outcomes related to pain, function, or quality of life.”
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Finding
Long-term opioid therapy was associated with problematic patterns of opioid use leading to clinically significant impairment or distress.
“Long-term opioid therapy was associated with problematic patterns of opioid use leading to clinically significant impairment or distress.”
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Finding
Initiation of ER/LA opioids was associated with greater nonfatal overdose risk than initiation with immediate-release opioids in one study, especially in the first two weeks.
“Initiation of therapy with an extended-release/long-acting(ER/LA) opioid was associated with greater risk of nonfatal overdose than initiation with an immediate-release opioid in 1 study, with risk greatest in the first 2 weeks after initiation of treatment.”
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Finding
The guideline intends to improve communication, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.
“The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.”
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Finding
The guideline contains 12 recommendations.
“There are 12 recommendations.”
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Finding
Clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible.
“Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.”
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Finding
The guideline recommends that nonpharmacologic therapy and nonopioid pharmacologic therapy be preferred for chronic pain.
“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.”
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Finding
When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids.
“When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.”
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Finding
Opioid-related overdose risk was dose-dependent, with higher dosages associated with increased overdose risk.
“Opioid-related overdose risk was dose-dependent, with higher opioid dosages associated with increased overdose risk (Table2).”
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Finding
Clinicians should evaluate benefits and harms within 1 to 4 weeks of starting opioid therapy or dose escalation and then every 3 months or more often.
“Clinicians should evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 months or more frequently.”
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Method
The guideline's objective is to provide opioid-prescribing recommendations for primary care clinicians treating adults with chronic pain outside cancer, palliative, and end-of-life care.
“To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care.”
Quote in the paperNot yet classified
Method
CDC updated a 2014 systematic review and conducted a supplemental review on benefits, harms, values and preferences, and costs, using GRADE to assess evidence and determine recommendation category.
“The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category.”
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Background
The paper states that opioid use is associated with serious risks, including opioid use disorder and overdose.
“Opioid use is associated with serious risks, including opioid use disorder and overdose.”
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Background
The paper states that evidence of long-term opioid efficacy for chronic pain is limited.
“Evidence of long-term efficacy of opioids for chronic pain is limited.”
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Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

More than a quarter of patients in a study of almost 100,000 were tapering at a rate faster than 40% of their original dose per month, even higher than the maximum rate recommended by the CDC.
“A study of almost 100,000 patients found that the average rate of tapering was 34.0% of the original dose per month and more than a quarter of patients were tapering at a rate faster than 40% of their original dose per month,43,49 even higher than the maximum rate recommended by the CDC. 1”
From Tapering and withdrawing opioids: guidance informed by fundamental principles to minimise withdrawal symptoms (2025) · cites this paper as [1]
The Recommendations section describes a decrease of 10% of the original dose per week as a reasonable starting point, not a maximum rate. It also says tapering plans may be individualized and more rapid tapers might be needed after an overdose. The study's patient counts and tapering rates are attributed to other citations in the citing sentence, not to this CDC guideline. (LLM, conf=0.89)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measured
Opioids are significantly less effective against chronic pain (neuropathic pain, fibromyalgia, low-back pain) and tolerance develops to their analgesic effects, necessitating higher doses.
“However, opioids are significantly less effective against chronic pain, such as neuropathic pain, fibromyalgia, and low-back pain, and tolerance develops to the analgesic effects of opioids, thus necessitating the need for increasingly higher doses to sustain analgesia (McQuay, 1988;Dowell et al., 2016).”
From Drug Addiction: Hyperkatifeia/Negative Reinforcement as a Framework for Medications Development (2021) · cites this paper as Dowell et al., 2016
The Clinical Evidence Review (page not provided) says opioids provide moderate short-term pain relief and that tolerance can diminish response over time, while long-term benefit for chronic pain remains uncertain. It does not establish that opioids are significantly less effective for the three named conditions or that tolerance necessitates increasingly higher doses; the Recommendations instead advise reassessment when dose requirements escalate. (LLM, conf=0.85)
Experimental — accuracy not yet measured
The CDC Guideline for Prescribing Opioids recommends a linear reduction of opioid doses: a decrease of 10% of the original dose per week or slower tapers such as 10% per month for longer term users.
“The influential Centres for Disease Control (CDC) Guideline for Prescribing Opioids recommends a linear reduction of opioid doses: ‘A decrease of 10% of the original dose per week’ or ‘slower tapers (e.g. 10% per month)’ for longer term users (Figure 1(a)). 1”
From Tapering and withdrawing opioids: guidance informed by fundamental principles to minimise withdrawal symptoms (2025) · cites this paper as [1]
Opioids are associated with substantial systemic harm such as worsening psychopathology, addiction, tolerance, and premature death.
“Opioids are also associated with substantial systemic harm such as worsening psychopathology, addiction, tolerance, and premature death. 24”
From Rome IV Functional Gastrointestinal Disorders and Health Impairment in Subjects With Hypermobility Spectrum Disorders or Hypermobile Ehlers-Danlos Syndrome (2021) · cites this paper as [24]
The Centers for Disease Control and Prevention and FDA issued warnings in 2016 to make prescribers and patients aware of risks of combining benzodiazepines with other CNS depressants.
“The Centers for Disease Control and Prevention and US Food and Drug Administration issued warnings in 2016 to make prescribers and patients aware of these risks.19,34”
From Patterns in Outpatient Benzodiazepine Prescribing in the United States (2019) · cites this paper as [34]

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Authors: Dowell, D., Haegerich, T. M., & Chou, R.
Affiliations: Centers for Disease Control and Prevention (US)
Corresponding author: Dowell, Deborah
ORCID: Dowell, Deborah
Haegerich, Tamara M.
Chou, Roger
Venue: JAMA
Publisher: American Medical Association (AMA)
Published: 2016-04-19
Volume: 315
Issue: 15
Pages: 1624
ISSN: 0002-9955 (ISSN-L)
0098-7484
DOI: 10.1001/jama.2016.1464
PMC: PMC6390846
OpenAlex: W2296986887
Cited by: 5,161
References: 215
Citations by year: 2026: 137 · 2025: 233 · 2024: 272 · 2023: 347 · 2022: 407 · 2021: 733 · 2020: 825 · 2019: 762 · 2018: 701 · 2017: 525 · 2016: 214 · 2015: 1 · 2014: 1
FWCI: 723.61
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: JAMA (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: National Institutes of Health (CC999999)
Agency for Healthcare Research and Quality
U.S. Public Health Service (200-2013-M-53890, 15IPA-1505478, 290201200014I)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
Keywords: opioid prescribing, chronic pain, opioid use disorder, opioid overdose, benzodiazepines, prescription drug monitoring programs, buprenorphine, methadone, medication-assisted treatment, low-dose opioids, primary care
MeSH terms: Contraindications, Adult, Analgesics, Opioid, Benzodiazepines, Centers for Disease Control and Prevention, U.S., Communication, Drug Therapy, Combination, Goals, Humans, Drug Prescriptions, Primary Health Care, United States, Randomized Controlled Trials as Topic, Treatment Outcome, Withholding Treatment, Chronic Pain, Acute Pain, Prescription Drug Misuse, Observational Studies as Topic

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CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

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