Prescription painkillers should not be a first choice for treating common ailments like back pain and arthritis, according to new US federal guidelines designed to reshape how doctors prescribe drugs such as OxyContin and Vicodin.
Amid an epidemic of addiction and abuse tied to these powerful opioid drugs, the Centers for Disease Control and Prevention is urging primary care doctors to try physical therapy, exercise and over-the-counter pain medications before turning to painkillers for chronic pain.
Opioid drugs include medications like morphine and oxycodone as well as illegal narcotics like heroin.
The new recommendations - which doctors do not have to follow - represent an effort to reverse nearly two decades of rising painkiller use, which public health officials blame for a more than four-fold increase in overdose deaths tied to the drugs.
In 2014, US doctors wrote nearly 200 million prescriptions for opioid painkillers, while deaths linked to the drugs climbed to roughly 19,000 - the highest number on record.
"We're trying to chart a safer and more effective course for dealing with chronic pain," Dr Tom Frieden, the CDC's director, said in an interview with the Associated Press.
"The risks of addiction and death are very well documented for these medications."
More than 40 Americans die every day from painkiller overdoses, a staggering rate that Frieden said is "doctor driven".
Under the new guidelines, doctors would prescribe painkillers only after considering non-addictive pain relievers, behavioural changes and other options.
The CDC also wants doctors to prescribe the lowest effective dose possible. And doctors should only continue prescribing the drugs if patients show significant improvement.
For short-term pain, the CDC recommends limiting opioids to three days of treatment, when possible.
The guidelines do not apply to doctors who specialise in treating severe pain due to cancer and other debilitating diseases.
Though the guidelines are voluntary, they could be widely adopted by hospitals, insurers and state and federal health systems.
Government officials have already tried multiple approaches to tackling painkiller abuse.
The Food and Drug Administration restricted some widely-prescribed painkillers to limit refills.
States like Florida and New York have cracked down on "pill mills" using databases to monitor what doctors are prescribing.
And this week, Massachusetts signed into law a seven-day limit on first-time prescriptions for opioids - the first of its kind in the nation.
"Changing medical practice isn't quick and it isn't easy," Frieden said.
"But we think the pendulum on pain management swung way too far toward the ready use of opioids."
Some leading medical groups have stopped short of embracing the recommendations.
The American Medical Association, the largest professional group for physicians, cautioned that the guidelines could create problems if they steer patients towards pain treatments that aren't accessible or covered by insurance.
"If they produce unintended consequences, we will need to mitigate them" said Dr Patrice Harris, in a statement.
"They are not the final word."
In many ways, the guidelines are a return to older medical practice.
Physicians trained in the 1960s and 70s - amid a wave of urban heroin use - were taught to reserve opioids for the most severe forms of pain, such as cancer or end-of-life care. That approach remains accepted.
But in the 90s, some specialists argued that doctors were undertreating common forms of pain that could benefit from opioids, such as backaches and joint pain.
The message was amplified by multimillion-dollar promotional campaigns for new, long-acting drugs like OxyContin, which was promoted as less addictive.
OxyContin's maker, Purdue Pharma, later agreed to plead guilty for misleading the public about the drug's risks.
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