Highlighted Updates: 2022 Clinical Practice Guideline

Broader clinical audience

The 2022 Clinical Practice Guideline broadens the scope from primary care physicians to include additional clinicians whose practice areas include prescribing opioids in outpatient settings (including upon discharge from hospital, emergency departments, and other facilities) for patients 18 years or older.

The 2022 Clinical Practice Guideline includes recommendations for:

• Family physicians
• Nurse practitioners
• Physician assistants
• Internists
• Dental and other oral health clinicians
• Emergency clinicians for patients being discharged from emergency departments
• Surgeons
• Occupational medicine physicians
• Physical medicine and rehabilitation physicians
• Neurologists
• Obstetricians and gynecologists

The 2022 Clinical Practice Guideline refers to and promotes integrated pain management and collaborative working relationships among clinicians, including, for example, behavioral health specialists such as social workers or psychologists, pharmacists, and registered nurses.

Five guiding principles for implementing recommendations

These five guiding principles are intended to inform the implementation of the recommendations from the 2022 Clinical Practice Guideline:

1. Acute, subacute, and chronic pain needs to be appropriately assessed and treated independent of whether opioids are part of a treatment regimen.

2. Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient is paramount.

3. A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.A

4. Special attention should be given to avoid misapplying this clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended and potentially harmful consequences for patients.

5. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities; provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities; and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons.

Acute pain guidance expanded with new data

The 2022 Clinical Practice Guideline includes guidance on prescription opioids for acute pain (duration less than 1 month). Nonopioid therapies are at least as effective as opioids for many common types of acute pain, including but not limited to low back pain, neck pain, pain related to other musculoskeletal injuries (such as sprains, strains, tendonitis, bursitis), and pain related to minor surgeries (Recommendation 1).

Subacute pain

The 2022 Clinical Practice Guideline includes content on management of subacute pain (duration of 1-3 months). Critical opportunities to reassess a patient's prescriptions during the subacute time frame are highlighted to ensure that opioid prescribing for acute pain does not unintentionally become long-term opioid therapy.

Initial and ongoing opioid therapy

The guidance aims to clearly delineate recommendations that apply to patients who are:

1. Being considered for Initial Opioid Therapy, or
2. Continuing Opioid Therapy as part of their ongoing pain management.

Opioid tapering

The benefits and the risks of opioid therapy change over time and should be re-evaluated periodically (Recommendations 6 and 7). Recommendation 5 outlines situations when clinicians should consider tapering to a reduced opioid dosage or tapering and discontinuing opioid therapy and that these approaches should be discussed with patients prior to initiating changes.

Recommendation 5 includes revised and expanded guidance on key topics during tapering to support opioid tapering when indicated.

• Deciding if and how to start tapering
• Pain management
• Behavioral health and patient support
• Management of opioid withdrawal
• Challenges
• Continuing high-dosage opioids

Considerations for opioid dosages

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.

Opioid dosage guidance was updated regarding:

• Suggestions for the lowest starting dose for opioid-naïve patients.
• Morphine milligram equivalent doses for commonly prescribed opioids.
• The approach to potential dosage increases, emphasizing principles of safe and effective pain treatment that allow for individual circumstances and flexibility in care.

Nonopioid therapies

All patients with pain should receive treatment that provides the greatest benefits relative to risks. This includes consideration of nonopioid therapies. The 2022 Clinical Practice Guideline has expanded guidance on nonopioid options for pain such as:

Nonpharmacologic therapies

• Ice
• Heat
• Elevation
• Rest
• Immobilization and/or exercise
• Exercise (such as aerobic, aquatic, and/or resistance exercise)
• Exercise therapy (a prominent modality in physical therapy)
• Mind-body practices (e.g., yoga, tai chi, qigong)
• Weight loss
• Psychological therapy (e.g., cognitive behavioral therapy)
• Manual therapies
• Mindfulness-based stress reduction
• Low-level laser therapy
• Acupuncture
• Massage
• Spinal manipulation

Nonopioid pharmacologic therapies

• Topical or oral non-steroidal anti-inflammatory drugs (NSAIDs)
• Acetaminophen

Health equity and disparities in the treatment of pain

The 2022 Clinical Practice Guideline describes evidence about long-standing health disparities that exist in the treatment of pain, such as geographic disparities and disparities in treatment due to access and affordability. It also highlights the importance of attention to health inequities related to race and ethnicity, as a guiding principle for implementation.