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LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html

GUIDELINE FOR PRESCRIBING 

OPIOIDS FOR CHRONIC PAIN

IMPROVING PRACTICE THROUGH RECOMMENDATIONS

CDC’s Guideline for Prescribing Opioids for Chronic Pain is intended to improve communication between providers and 

patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain 

treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder and overdose. 

The Guideline is not intended for patients who are in active cancer treatment, palliative care, or end-of-life care.

DETERMINING WHEN TO INITIATE OR CONTINUE OPIOIDS FOR CHRONIC PAIN

Nonpharmacologic therapy and nonopioid pharmacologic therapy 

are preferred for chronic pain. Clinicians should consider opioid 

therapy only if expected benefits for both pain and function are 

anticipated to outweigh risks to the patient. If opioids are used, 

they should be combined with nonpharmacologic therapy and 

nonopioid pharmacologic therapy, as appropriate.

Before starting opioid therapy for chronic pain, clinicians 

should establish treatment goals with all patients, including 

realistic goals for pain and function, and should consider how 

opioid therapy will be discontinued if benefits do not outweigh 

risks. Clinicians should continue opioid therapy only if there is 

clinically meaningful improvement in pain and function that 

outweighs risks to patient safety. 

Before starting and periodically during opioid therapy, clinicians 

should discuss with patients known risks and realistic benefits 

of opioid therapy and patient and clinician responsibilities for 

managing therapy.

CLINICAL REMINDERS

• Opioids are not first-line or routine 

therapy for chronic pain

• Establish and measure goals for pain 

and function

• Discuss benefits and risks and 

availability of nonopioid therapies with 

patient
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OPIOID SELECTION, DOSAGE, DURATION, FOLLOW-UP, AND DISCONTINUATION

When starting opioid therapy for chronic pain, clinicians should prescribe 

immediate-release opioids instead of extended-release/long-acting (ER/LA) 

opioids.

When opioids are started, clinicians should prescribe the lowest effective dosage. 

Clinicians should use caution when prescribing opioids at any dosage, should 

carefully reassess evidence of individual benefits and risks when considering 

increasing dosage to ≥50 morphine milligram equivalents (MME)/day, and should 

avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate 

dosage to ≥90 MME/day.

Long-term opioid use often begins with treatment of acute pain. When opioids 

are used for acute pain, clinicians should prescribe the lowest effective dose of 

immediate-release opioids and should prescribe no greater quantity than needed 

for the expected duration of pain severe enough to require opioids. Three days or 

less will often be sufficient; more than seven days will rarely be needed.

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. If benefits do not outweigh harms of continued opioid 

therapy, clinicians should optimize other therapies and work with patients to 

taper opioids to lower dosages or to taper and discontinue opioids.

CLINICAL REMINDERS

• Use immediate-release opioids 

when starting

• Start low and go slow

• When opioids are needed for 

acute pain, prescribe no more 

than needed

• Do not prescribe ER/LA opioids 

for acute pain

• Follow-up and re-evaluate risk 

of harm; reduce dose or taper 

and discontinue if needed 

ASSESSING RISK AND ADDRESSING HARMS OF OPIOID USE

Before starting and periodically during continuation of opioid therapy, clinicians 

should evaluate risk factors for opioid-related harms. Clinicians should incorporate 

into the management plan strategies to mitigate risk, including considering offering 

naloxone when factors that increase risk for opioid overdose, such as history of 

overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), 

or concurrent benzodiazepine use, are present. 

Clinicians should review the patient’s history of controlled substance prescriptions 

using state prescription drug monitoring program (PDMP) data to determine 

whether the patient is receiving opioid dosages or dangerous combinations that 

put him or her at high risk for overdose. Clinicians should review PDMP data when 

starting opioid therapy for chronic pain and periodically during opioid therapy for 

chronic pain, ranging from every prescription to every 3 months.

When prescribing opioids for chronic pain, clinicians should use urine drug testing 

before starting opioid therapy and consider urine drug testing at least annually to 

assess for prescribed medications as well as other controlled prescription drugs and 

illicit drugs.

Clinicians should avoid prescribing opioid pain medication and benzodiazepines 

concurrently whenever possible.

Clinicians should offer or arrange evidence-based treatment (usually medicationassisted treatment with buprenorphine or methadone in combination with 

behavioral therapies) for patients with opioid use disorder.

CLINICAL REMINDERS

• Evaluate risk factors for 

opioid-related harms

• Check PDMP for high dosages 

and prescriptions from other 

providers

• Use urine drug testing to identify 

prescribed substances and 

undisclosed use 

• Avoid concurrent benzodiazepine 

and opioid prescribing

• Arrange treatment for opioid use 

disorder if needed

LEARN MORE | www.cdc.gov/drugoverdose/prescribing/guideline.html