Summary This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain. The recommendations do not apply to pain related to sickle cell disease or cancer or to patients receiving palliative or end-of-life care. The guideline addresses the following four areas: 1) determining whether or not to initiate opioids for pain, 2) selecting opioids and determining opioid dosages, 3) deciding duration of initial opioid prescription and conducting follow-up, and 4) assessing risk and addressing potential harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework. Recommendations are based on systematic reviews of the scientific evidence and reflect considerations of benefits and harms, patient and clinician values and preferences, and resource allocation. CDC obtained input from the Board of Scientific Counselors of the National Center for Injury Prevention and Control (a federally chartered advisory committee), the public, and peer reviewers. CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.

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CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022

Importance Opioid-related mortality and national prescribing guidelines have led to tapering of doses among patients prescribed long-term opioid therapy for chronic pain. There is limited information about risks related to tapering, including overdose and mental health crisis. Objective To assess whether there are associations between opioid dose tapering and rates of overdose and mental health crisis among patients prescribed stable, long-term, higher-dose opioids. Design, Setting, and Participants Retrospective cohort study using deidentified medical and pharmacy claims and enrollment data from the OptumLabs Data Warehouse from 2008 to 2019. Adults in the US prescribed stable higher doses (mean ≥50 morphine milligram equivalents/d) of opioids for a 12-month baseline period with at least 2 months of follow-up were eligible for inclusion. Exposures Opioid tapering, defined as at least 15% relative reduction in mean daily dose during any of 6 overlapping 60-day windows within a 7-month follow-up period. Maximum monthly dose reduction velocity was computed during the same period. Main Outcomes and Measures Emergency or hospital encounters for (1) drug overdose or withdrawal and (2) mental health crisis (depression, anxiety, suicide attempt) during up to 12 months of follow-up. Discrete time negative binomial regression models estimated adjusted incidence rate ratios (aIRRs) of outcomes as a function of tapering (vs no tapering) and dose reduction velocity. Results The final cohort included 113 618 patients after 203 920 stable baseline periods. Among the patients who underwent dose tapering, 54.3% were women (vs 53.2% among those who did not undergo dose tapering), the mean age was 57.7 years (vs 58.3 years), and 38.8% were commercially insured (vs 41.9%). Posttapering patient periods were associated with an adjusted incidence rate of 9.3 overdose events per 100 person-years compared with 5.5 events per 100 person-years in nontapered periods (adjusted incidence rate difference, 3.8 per 100 person-years [95% CI, 3.0-4.6]; aIRR, 1.68 [95% CI, 1.53-1.85]). Tapering was associated with an adjusted incidence rate of 7.6 mental health crisis events per 100 person-years compared with 3.3 events per 100 person-years among nontapered periods (adjusted incidence rate difference, 4.3 per 100 person-years [95% CI, 3.2-5.3]; aIRR, 2.28 [95% CI, 1.96-2.65]). Increasing maximum monthly dose reduction velocity by 10% was associated with an aIRR of 1.09 for overdose (95% CI, 1.07-1.11) and of 1.18 for mental health crisis (95% CI, 1.14-1.21). Conclusions and Relevance Among patients prescribed stable, long-term, higher-dose opioid therapy, tapering events were significantly associated with increased risk of overdose and mental health crisis. Although these findings raise questions about potential harms of tapering, interpretation is limited by the observational study design.

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Association of Dose Tapering With Overdose or Mental Health Crisis Among Patients Prescribed Long-term Opioids

Shared decision-making (SDM) is a widely-advocated practice that has been linked to improved patient adherence, satisfaction, and clinical outcomes. SDM is a process in which patients and providers share information, express opinions, and build consensus toward a treatment decision. Chronic pain and its treatment present unique challenges for SDM, especially in the current environment in which opioids are viewed as harmful and a national opioid crisis has been declared. The purpose of this qualitative study is to understand treatment decision-making with patients taking opioids for chronic pain. Ninety-five clinic visits and 31 interviews with patients and primary care providers (PCPs) were analyzed using the constant comparison method. Results revealed that 1) PCPs desire patient participation in treatment decisions, but with caveats where opioids are concerned; 2) Disagreements about opioids, including perceptions of lack of listening, presented challenges to SDM; and 3) PCPs described engaging in persuasion or negotiation to convince patients to try alternatives to opioids, or appeasing patients requesting opioids with very small amounts in an effort to maintain the patient-provider relationship. Results are discussed through the lens of Charles, Gafni, and Whelan's SDM model, and implications of the role of the patient-provider relationship in SDM and chronic pain treatment are discussed.

Managing Chronic Pain in an Opioid Crisis: What Is the Role of Shared Decision-Making?

To cite: Elwyn G, Price A, Franco JVA, et al. BMJ EvidenceBased Medicine Epub ahead of print: [please include Day Month Year]. doi:10.1136/ bmjebm-2022-112089 © Author(s) (or their employer(s)) 2022. Reuse permitted under CC BYNC. No commercial reuse. See rights and permissions. Published by BMJ. The foundation of shared decision making (SDM) is the view that people should be aware of relevant choices, and that their personal views, priorities and preferences are relevant factors when determining action. The degree to which people wish to engage in decisions will vary, as will the level to which they will be made aware that decisions exist, or become informed about the relevant information. There is increasing interest in SDM, an ethical imperative, and supporting evidence that welldesigned tools help people compare options and make more informed choices. We as authors, are strong advocates of SDM, and think the approach can be applied widely, perhaps more widely than many health professionals think possible. 5 Nevertheless we have identified situations where we consider there to be clear limits to SDM, where wider interests can override the priority given to individual preferences. While we think individual priorities and preferences should be respected where possible, there are situations where other factors determine decisions. We feel it is essential to make these situations clear. SDM can be too easily dismissed as an impossible ideal if we do not acknowledge that the approach has limitations. In addition, delineating exceptions will serve to illustrate the demarcation between what can be thought of as the pinnacle of patientcentred care and situations where the approach is rightly constrained by ethical, professional or societal factors. First, let’s agree that decisions come in different forms: some are conscious and episodic, as in ‘Shall I have this procedure?’. Some are the result of commitment decisions, such as when agreeing to take medication for a longterm illness. Others go unnoticed in conversations, such as when a clinician suggests a solution and results in assumed acceptance. Such subtle decisions may well occur because of deference to an expert or an unwillingness to disagree. SDM makes the process of determining decisions more explicit, and in healthcare the skills of supporting people to become aware, consciously deliberate, and arrive at betterconsidered decisions, whether for irreversible or continuous actions, are of utmost value. The steps suggested to achieve SDM have been extensively described elsewhere. It therefore follows that SDM can be applied to a wide range of situations. When there is no evidence that any one management option is considered superior to another reasonable option, then SDM could be seen as a necessary approach. This situation has been described as one where clinical equipoise exists. Indeed, it might even be considered unethical not to provide information about alternatives in such situations. 13 More common, however, is the situation where a range of options exist and where the extent of evidence, and its quality, varies considerably, exacerbating uncertainty. Sometimes the evidence is sparse or poor, or points in different directions, yet there are reasonable options, including the potential watchful waiting or taking no action. Sometimes there is good evidence and high certainty, but even so there are important tradeoffs to consider, such as side effects, or other burdens and costs. In these scenarios, individual preferences will contribute to an assessment of what action to take. To the degree that it is reasonable to compare options, these situations also qualify as having clinical equipoise. SDM is necessary because there will always be a need to consider harms alongside benefits, and critically, the weighting of those factors will vary according to the priorities and preferences of people who will live with the consequences of decisions made, and the tradeoffs they are willing to make. However, there are also situations where taking a shared approach to decisions is not possible, although this does not rule out the need to provide empathetic care. There are limits to SDM, and the goal of this article is to be clear about the type of situations where SDM faces limits and where other strategies will need to be considered. Limits on SDM will occur when: ► Wider interests override individual wishes ► Evidence of benefit is insufficient or absent ► Lowered decisional capacity is present ► Profound existential uncertainty exists.

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The limits of shared decision making

Opioid-induced hyperalgesia (OIH) occurs when opioids paradoxically enhance the pain they are prescribed to ameliorate. To address a lack of perioperative awareness, we present an educational review of clinically relevant aspects of the disorder. Although the mechanisms of OIH are thought to primarily involve medullary descending pathways, it is likely multifactorial with several relevant therapeutic targets. We provide a suggested clinical definition and directions for clinical differentiation of OIH from other diagnoses, as this may be confusing but is germane to appropriate management. Finally, we discuss prevention including patient education and analgesic management choices. As prevention may serve as the best treatment, patient risk factors, opioid mitigation, and both pharmacologic and non-pharmacologic strategies are discussed.

Mechanisms, diagnosis, prevention and management of perioperative opioid-induced hyperalgesia.

Patients’ Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians

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Patients’ Experience With Opioid Tapering: A Conceptual Model With Recommendations for Clinicians