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KEY POINTS• We recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids, for patients with chronic noncancer pain.

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for the Evidence-Based Medicine Working Group CLINICAL SCENARIO You are working as an internal medicine resident in a rheumatology rotation and are seeing a 19-year-old woman who has had systemic lupus erythematosus diagnosed on the basis of a characteristic skin rash, arthritis, and renal disease. A renal biopsy has shown diffuse proliferative nephritis. A year ago her creatinine level was 140 \g=m\mol/L, 6 months ago it was 180 \g=m\mol/L, and in a blood sample taken a week before this clinic visit, 220 \g=m\mol/L. Over the last year she has been taking prednisone, and over the last 6 months, cyclophosphamide, both in appropriate doses.