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Treating chronic pain without opioids: what the CDC guideline says
The CDC's 2022 clinical guideline prefers nonopioid therapies for chronic pain. Here are the options it supports for each type of pain.
PainManagement ER Published 3 min read
For years, opioids were often prescribed for pain that wouldn’t go away. Today clinical guidelines point in another direction. The CDC’s 2022 Clinical Practice Guideline — the official U.S. reference for prescribing opioids — states that “nonopioid therapies are preferred for subacute and chronic pain.”[1]
That doesn’t mean pain goes untreated. It means there is a wide range of options, with and without medication, that should be used first.
The two key recommendations
The CDC guideline contains 12 recommendations. The first two set the overall approach:[1]
- Acute pain: nonopioid therapies are at least as effective as opioids for many common types of acute pain. Clinicians should make the most of non-drug treatments and nonopioid medications, and only consider opioids if benefits are expected to outweigh risks.
- Subacute (1 to 3 months) and chronic (more than 3 months) pain: nonopioid therapies are preferred. Opioids should only be considered if expected benefits for pain and function outweigh the risks.
In both cases, the guideline asks clinicians to discuss realistic benefits and known risks with patients before starting treatment.[1]
Options by type of pain
The CDC guideline reviews the available evidence for several common conditions. This table summarizes the options it mentions:[1]
| Condition | Non-drug therapies | Nonopioid medications |
|---|---|---|
| Chronic low back pain | Exercise therapy, psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture and multidisciplinary rehabilitation | If those are not enough: NSAIDs or duloxetine |
| Knee and hip osteoarthritis | Exercise (aerobic, aquatic or resistance); weight loss (knee); manual therapy (hip) | Topical NSAIDs for one or a few joints near the skin, such as the knee; duloxetine or oral NSAIDs for multiple joints or when control is inadequate |
| Fibromyalgia | Cognitive behavioral therapy, myofascial release massage, mindfulness, tai chi, qigong, acupuncture and multidisciplinary rehabilitation | Tricyclic antidepressants (e.g., amitriptyline), SNRIs (e.g., duloxetine, milnacipran), topical diclofenac, pregabalin or gabapentin |
| Neuropathic pain | — | Tricyclic, tetracyclic and SNRI antidepressants; selected anticonvulsants (pregabalin, gabapentin enacarbil, oxcarbazepine); capsaicin or lidocaine patches |
| Episodic migraine (attacks) | Remote electrical neuromodulation (potentially effective) | Triptans, NSAIDs, triptans combined with NSAIDs, antiemetics, dihydroergotamine, acetaminophen; also gepants and lasmiditan |
Source: CDC, Clinical Practice Guideline for Prescribing Opioids for Pain (2022).[1] No medication should be taken without medical advice: each one has contraindications and side effects.
On fibromyalgia, the guideline is especially clear: the benefits of opioids are unlikely to outweigh their risks.[1]
The WHO agrees
The WHO’s first guideline on chronic low back pain, published in December 2023, also recommends exercise, education, psychological support, spinal manipulation, massage and NSAIDs, and advises against opioid painkillers, traction and lumbar braces.[2]
Why this approach matters
With nearly 1 in 4 U.S. adults living with chronic pain in 2023,[3] finding treatments that are effective and safe over the long term is essential. The guidelines share three ideas:
- Combining several therapies often works better than relying on a single pill.
- Movement is treatment: exercise shows up as an option for almost every condition.
- The mind matters too: psychological therapy and mindfulness are part of the recommendations for chronic low back pain and fibromyalgia.[1]
If you already take opioids
Don’t stop or change your medication on your own. The CDC guideline stresses that any change should be individualized and agreed on with your clinician, avoiding abrupt discontinuation.[1]
A well-designed pain management plan combines diagnosis, movement, emotional support and, when needed, procedures or medications suited to your case.
Sources
- CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022 . Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. MMWR Recomm Rep 2022;71(No. RR-3):1–95, CDC , November 4, 2022.
- Do's and don'ts for tackling chronic back pain (WHO chronic low back pain guideline) . UN News , December 7, 2023.
- Chronic Pain and High-impact Chronic Pain in U.S. Adults, 2023 (NCHS Data Brief No. 518) . Lucas JW, Sohi I. National Center for Health Statistics, CDC , November 2024.
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