Opioids – Support for Providers

CDC Guideline for Prescribing Opioids for Chronic Pain²

Determining when to Initiate or Continue Opioids for Chronic Pain

1. Opioids should not be first-line therapy for acute pain
Clinicians should prioritize nonopioid treatments for acute pain, using them as first-line options. Opioids should only be considered if the benefits outweigh the risks, with a thorough discussion of the potential benefits and risk with the patient beforehand.

2. Opioids should not be first-line therapy for subacute and chronic pain
Nonopioid treatments are also preferred for subacute and chronic pain. Clinicians should prioritize nonpharmacologic and nonopioid options, considering opioids only if the benefits for pain and function outweigh the risks. Before starting opioids, clinicians should discuss benefits and risks with patients, set treatment goals, and plan for discontinuation if benefits do not outweigh risks.

*Pain classified as:

• Outpatients aged ≥18 years with acute (duration of <1 month), subacute (duration of 1-3 months), or chronic (duration of >3 months) pain
• Excluding pain management related to sickle cell disease, cancer-related pain treatment, palliative care, and end-of-life care

Selecting Opioids and Determining Opioid Dosages

3. Prescribe immediate-release opioids for pain management
When initiating opioid therapy for acute, subacute, or chronic pain, clinicians should prescribe immediate-release opioids rather than extended-release/long-acting (ER/LA) opioids.

4. Use the lowest effective dose
For opioid-naïve patients with acute, subacute, or chronic pain, clinicians should start with the lowest effective dose [5-10 morphine milligram equivalents (MME)/dose or 20-30 MME/day]. Before increasing dosage to ≥50 MME/day, clinicians should reassess individual benefits and risks. Dosage increases beyond 50 MME/day are more likely to provide diminishing returns in pain relief and increased risks. Therefore, providers should carefully evaluate further dosage increases based on diagnosis, prior increases, alternative treatments, and patient preferences.

5. Manage opioid dosage adjustments and taper in ongoing therapy
When adjusting opioid therapy, clinicians should carefully weigh the benefits and risks. If continued opioid use is justified, they should optimize nonopioid therapies. If not, clinicians should work with patients to gradually taper opioids or discontinue them as appropriate, avoiding abrupt reductions unless there is a life-threatening issue.

Deciding Duration of Initial Opioid Prescription and Conducting Follow-Up

6. Prescribe short durations for acute pain
Clinicians should prescribe opioids only for the expected duration of acute pain, typically 3-7 days. For longer use, regular reassessment is crucial to avoid transitioning to long-term opioid therapy. If opioids are used for more than a few days, a taper plan should be discussed to prevent withdrawal symptoms. Prolonged pain requires timely reevaluation and adjustment of treatment as needed.

7. Evaluate benefits and risks frequently
Clinicians should evaluate the benefits and risks with patients within 1-4 weeks of starting opioid therapy for subacute or chronic pain or after dosage escalation. Benefits and risks should be reevaluated every 3 months or more frequently. If the benefits no longer outweigh the risks, clinicians should optimize other therapies and work with patients to taper opioids or discontinue them.

Assessing Risk and Addressing Potential Harms of Opioid Use

8. Use strategies to mitigate risk
Before starting and periodically during opioid therapy, clinicians should evaluate the risk of opioid-related harms and discuss these risks with patients. Clinicians should work with patients to incorporate strategies to mitigate these risks, including offering naloxone, especially when factors like a history of overdose, substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use are present.

9. Review Prescription Drug Monitoring Program (PDMP) data
Clinicians should review the patient’s history of controlled substance prescriptions using state PDMP data when starting opioid therapy for acute, subacute, or chronic pain, and periodically during treatment for chronic pain. This helps determine whether the patient is receiving opioid dosages or dangerous combinations that put them at high risk for overdose. Reviews should occur at least every prescription or every 3 months.

10. Use urine drug testing
Clinicians prescribing opioids for subacute or chronic pain should conduct urine drug testing before starting therapy and at least annually to assess prescribed, controlled, and illicit substances. Toxicology testing, when used appropriately, helps improve patient safety and care without being punitive. It should be integrated with clinical judgement, patient communication, and efforts to identify risks and address substance use disorders.

11. Caution in concurrent prescribing of opioids and benzodiazepines

Clinicians should exercise caution when prescribing opioid pain medication alongside benzodiazepines and carefully evaluate whether the benefits outweigh the risks of using opioids with other central nervous system depressants.

12. Offer treatment for opioid use disorder
Clinicians should offer or arrange evidence-based treatment, typically medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies, for patients with opioid use disorder. Detoxification alone, without medications is not recommended due to increased risks of relapse, overdose, and overdose death.

Covered services are available to Medi-Cal members at no cost.

Billing Options for Opioid/Non-Opioid Pain Therapies^3,4

PA = prior authorization

*Most pain medications are self-administered and billed through the Pharmacy Benefit.  There are ad hoc situations in which pain medications may need to be administered by a physician, whereby resulting in billing the medical benefit.

Refer to Health Plan’s webpage for Pharmacy Drug Benefits: Pharmacy – HPSJ/MVHP

References:
1. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recomm Rep 2022;71(No. RR-3):1–95. DOI: http://dx.doi.org/10.15585/mmwr.rr7103a1.

2. Von Korff M, Saunders K, Ray GT, et al. Clin J Pain 2008;24:521–7 and Nielsen S, Degenhardt L, Hoban B, Gisev N. Pharmacoepidemiol Drug Saf 2016;25:733–7.
3. DHCS Medi-Cal Provider Manuals. Ca.gov. Published 2025. https://www.dhcs.ca.gov/formsandpubs/publications/Pages/Medi-CalProviderManuals.aspx
4. Medi-Cal Rx Contract Drugs List. Ca.gov. Published 2025. https://medi-calrx.dhcs.ca.gov/home/cdl/