Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Abstract

Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices. Perspective: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel following a systematic review of the evidence.

Low Use of Opioid Risk Reduction Strategies in Primary Care Even for High Risk Patients with Chronic Pain

“…[1][2][3][4][5] In response, pain management experts, medical societies, and regulatory agencies have published guidelines for long-term opioid treatment aimed at reducing opioid misuse, [6][7][8][9] the use of prescribed opioids other than as directed or indicated. 10 Recommendations include urine drug testing, regular face-toface office visits to evaluate patients' response to opioids and risk of misuse, and adhering to a pre-defined refill schedule (i.e., restricting refills of opioids prior to expiration of the previous prescription).…”

Pharmacotherapy of Opioid Addiction: “Putting a Real Face on a False Demon”

“…The American Pain Society published a white paper which states that methadone should never be the first opioid used in the treatment of pain [16,17]. Methadone has a high overdose death rate relative to other opioids [15].…”

“…Methadone has a high overdose death rate relative to other opioids [15]. Although methadone is an effective medication for the treatment of both addiction and pain, caution must be exercised in prescribing and additional training is warranted due to its unique pharmacokinetic profile [14,16]. Patients may be rapid metabolizers of methadone.…”

Chronic Opioid Therapy Urine Drug Testing in Primary Care: Prevalence and Predictors of Aberrant Results

“…2,[7][8][9][10][11] UDTs can help identify drug misuse/abuse (through detection of illicit drug, opioid, or benzodiazepine use unknown to the opioid prescriber) and diversion (a possibility when prescribed opioids are absent). However, little evidence exists regarding UDT use for various patient subgroups.…”

“…However, little evidence exists regarding UDT use for various patient subgroups. 12 Guidelines vary in their recommendations, with two 9,13 recommending mandatory testing for all COT patients, one advising testing for patients at risk for substance use disorders (SUDs), 8 and two 8,14 commenting that screening low-risk populations increases false-positive results and is less costeffective. 11 Knowledge regarding the risk factors for aberrant results could help inform evidence-based recommendations regarding UDTs for COT monitoring.…”