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New CDC Proposal Could Change How Doctors Prescribe Opioids for Pain Treatment

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Key Takeaways

  • The CDC proposed new guidelines for prescribing opioids for pain treatment, which will eliminate dosage caps and use 50 MME doses as a benchmark for added scrutiny and monitoring.
  • If approved, the change will allow some patients to receive higher doses for treatment.
  • But experts in pain medicine worry that removing limits could lead to over-prescribing opioids, hurting patients and aggravating the already raging overdose epidemic.

The Centers for Disease Control and Prevention (CDC) proposed to remove the recommended dosage caps on opioids for acute and chronic pain. The proposal also called for an individualized approach to care.

If approved, it would be a drastic change from the 2016 guidelines, which recommended a 90 MME cap for new patients.

What Is MME?

Morphine milligram equivalents (MME) represents how many milligrams of morphine equals the dose of the prescribed medication. According to the CDC, this metric helps monitor the overdose potential of opioids.

But some experts in pain medicine said removing dosage caps altogether could have dangerous consequences for patients seeking care.

“It’s very clear that high dose chronic opioid therapy is associated with a lot of adverse consequences, one of them being unintentional overdose and even death,” Lewis S. Nelson, MD, clinical chair in emergency medicine at Rutgers Medical School and former panelist for the creation of the 2016 guidelines, told Verywell.

"If you’re not getting better with a reasonable dose of an opioid, there’s no reason to think that giving more is going to do any better," Nelson said.

It isn’t a good idea to quickly lower a patient’s dosage to 90 MME either, especially if they were previously prescribed something much higher, he added.

There were several misgivings to the 2016 guidelines, including a misinterpretation by states and physicians that the guidelines were mandatory for all physicians, he said. The dosage cap in the 2016 guidelines wasn’t meant to police all pain medicine prescribers. However, some U.S. states also had different interpretations of the guidance and required a broad spectrum of physicians to abide by the CDC recommendation. As a result, some doctors refused to increase doses above 90 MME and chronic pain patients were barred from necessary care.

Peter Staats, MD, MBA, president of the World Institute of Pain, told Verywell that the 2016 guidelines “put patients at a substantive risk of having their medications withdrawn, and doctors being concerned that they would lose their license.”

CDC's New Proposal Highlights Individualized Care

The new proposal, which will apply to a broad range of physicians, recommends that people at already high opioid doses be put on a slow taper, noting that that cadence of the taper should be assessed individually.

For patients who had been taking opioids for a year or longer, the CDC proposed a 10% per month taper. For patients who are not able to taper, the proposal recommended they be closely monitored and provided with things like overdose prevention education and Naloxone. The exact dosage that they should be tapered to should be decided upon an individual basis, according to the document.

These recommendations apply to outpatients and exclude patients with sickle cell disease, cancer, palliative care, and end-of-life care.

For people starting opioid therapy, the agency recommended that providers use caution and reassess patients before raising dosages above 50MME a day. The agency did not designate this number as a dosage cap, but rather 50MME is the dosage standard where providers should use extra caution when prescribing above the threshold. Patients at or above 50MME should have more frequent follow-up visits and that they and their household members be provided with Naloxone and overdose prevention education, according to the document.

“The recommendations related to opioid dosages are not intended to be used as an inflexible, rigid standard of care; rather, they are intended to be guideposts to help inform clinician-patient decision making,” the agency wrote. They also noted that the 50MME recommendation did not apply to people being tapered off of higher doses.

High Dose Opioid Prescription

Providers who prescribe high opioid dosages should consider a very slow taper, rather than a sudden drop, to wane the patient down to 90 MME or an even lower level, Nelson said. According to the CDC, patients who have challenges tapering down doses should be assessed for opioid use disorder and provided with medication treatment as well as naloxone if necessary.

What Will the New Proposal Mean for Pain Patients?

The 2022 document stresses the importance of an individualized approach to care and provides a substantial review of opioid treatments, which can be powerful tools for many pain patients, Staats said.

However, the new proposal has very little information about non-opioid therapies for pain and insurance reimbursement, Staats added. Insurance companies may be less likely to cover non-opioid pain treatments than opioids if they’re not explicitly recommended by the CDC.

Only one section of the 211-page document is dedicated to non-opioid treatments, the cost of which was not addressed.

“I know they can’t get everything, but they had an exhaustive evaluation of pros and cons of opioids—highlighting a lot of the pros—and missed the opportunity to cover issues around alternative strategies,” Staats said.

When physicians prescribe opioids for pain, they should do so because they are making an appropriate and thoughtful decision about their patient’s health, and not because they are unaware of other options, he added.

Experts in pain medicine were largely excluded from the creation of the new guidelines, Staats added. “Having a group like this dictate what’s the appropriate pain care without having pain expertise is misguided,” he said. “Had they had expertise for pain management on this committee, they probably would have, or should have, realize that there really is not a well balanced approach.”

The CDC interviewed Staats prior to the creation of the document, but did not include his advice in its creation, he said.

Risk of Opioids in Pain Management

Between 8% and 12% of people who use opioids for chronic pain management develop opioid use disorder, and between 21% and 29% of patients prescribed opioids misuse them, according to the National Institute on Drug Abuse (NIDA). But it’s impossible to tell if someone will develop opioid use disorder if they’ve never used opioids.

“We all have different priming, we all have different risk factors,” Nelson said. “Every time we give an opioid to somebody, we are rolling the dice a little bit.”

People who use opioids can also develop a condition called hyperalgesia, where their tolerance for pain decreases as their time using opioids increases. 

“Basically what it means is that being on pain medications induces an adaptive response in your body that essentially makes the pain worse,” Nelson said. “It’s iterative, it builds on itself. The pain gets worse, you need more opioid, your pain gets worse, you need opioid.”

This is unsafe because a person’s dosage may not be enough to quell their pain, but increasing it can still have detrimental impacts on their respiratory system, he added. People who die of opioid overdose often die from respiratory depression, added.

Searching for Non-Opioid Alternatives

The Food and Drug Administration (FDA) will be taking steps aimed at developing non-addictive drugs for acute pain treatment.

“Prescribed appropriately, opioid analgesics are an important part of acute pain management. However, even at prescribed doses, they pose a risk for addiction, misuse, abuse or overdose that may result in death,” the agency wrote.

A non-addictive drug that rivals an opioid’s pain killing properties would be a groundbreaking treatment, Nelson said. But finding one won’t be easy.

Heroin was introduced in the 1800s as a potential non-addictive alternative to morphine. In 2020, it was responsible for 13,165 overdose deaths in the United States.

“History is paved with good intentions and bad outcomes,” Nelson said, adding that non-addictive opioids may be “a pipe dream.”

Without a universal, harmless solution to treating pain, opioids remain a powerful tool in aiding patients. But increasing knowledge and access to non-opioid therapies may be essential in making sure that opioid prescriptions don’t get out of control.

“We want to give autonomy to the physicians to make the right decisions for their patients,” Staats said. “But on the flip side, you can’t look at that in a vacuum. If you are telling physicians that the only tool that they have in their toolbox is opioids, they are going to increase the amount of medications that are prescribed and that’s going to be harmful.”

What This Means For You

Health officials proposed to lift dosage caps on opioids that are used for pain treatment and encouraged the use of non-opioid alternatives. Some experts say it could have dangerous consequences for patients seeking care. You can leave a public comment for the CDC proposal until April 11, 2022.

Correction - February 22, 2022: This article was updated to clarify the CDC's proposed changes to the 2016 guidelines with the 50MME benchmark.

3 Sources
Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
  1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1

  2. National Institute on Drug Abuse. Opioid overdose crisis.

  3. National Institute on Drug Abuse. Overdose death rates.

By Claire Wolters
Claire Wolters is a Philly-based reporter covering health news for Verywell. She is most passionate about stories that cover real issues and spark change.