Table 1.

The CDC guideline was framed as principles, which are summarized here [1]

	Short summary	Comment
1	Nonpharmacologic and nonopioid pharmacological therapies are preferred for chronic pain. When using opioids, combination therapy with a nonopioid analgesic is preferred
2	Establish treatment goals and use of opioids only as long as improvements in pain and function outweigh the risks	Elevation of “functional improvement” to be the equivalent of pain control is not based on the evidence. Some patients, for example, the bedbound, may need pain relief but never achieve much functional benefit from pain control
3	Physicians should discuss risks and benefits of opioids with patients before starting opioids and periodically thereafter; there are patient and clinician responsibilities in opioid therapy
4	Immediate-release opioids are preferred over extended-release or long-acting opioids	The CDC cautions that transdermal products require special patient education and are “often misunderstood.” However, there are reasons for the use of different opioid formulations that may override this blanket advice
5	Start with the lowest effective dosage and do not increase over 90 MME per day	Equianalgesic calculations (MME) are estimates and vary even among experts. Non-experts may have trouble establishing the MME for various opioid products. MME tables are in flux This cutoff rate does not appear to be supported by evidence but is an arbitrarily set value. It may not meet the needs of many long-term opioid patients
6	For acute pain, prescribe opioids for 3 days or fewer and rarely for over 7 days	While this may be true in many cases, there is no evidence that this is a good fit for all pain patients
7	Harms and benefits should be assessed within 1–4 weeks after starting opioids and at least quarterly thereafter	The CDC said that if benefits do not outweigh harms, patients should be tapered to lower doses or discontinued. Shared decision-making should be involved in discontinuing opioids and selecting other analgesic options
8	Risk factors should be assessed periodically and plans made to mitigate risk
9	Prescription drug monitoring program (PDMP) data should be checked to be sure the patient is not taking too many opioid or dangerous drug combinations	The CDC advises that checks should be made every time a prescription is added and at least quarterly even if nothing new is added Note that not all states have a PDMP and few programs effectively share their data with other states
10	Urine drug testing should be done at the outset of opioid therapy and at least annually	Urine drug testing is well established in this setting but it is unclear why urine screens could be limited to once a year
11	Opioids and benzodiazepines should not be taken concurrently	There may be cases where a patient taking opioids may require short-term benzodiazepine use
12	For patients who develop opioid use disorder, physicians should arrange for evidence-based treatment	The CDC does not define opioid use disorder, explain how it would be diagnosed, or advise as to what sort of treatments might be appropriate; this puts an undue burden on a primary care physician who is likely not equipped to manage this scenario. Opioid detoxification and rehabilitation are extremely challenging clinical situations that require significant expertise to manage effectively