Responsible Prescribing of Opioids for Chronic Non-Cancer Pain: A Scoping Review

Abstract

Chronic non-cancer pain is common and long-term opioid therapy is frequently used in its management. While opioids can be effective, they are also associated with significant harm and misuse, and clinicians must weigh any expected benefits with potential risks when making decisions around prescribing. This review aimed to summarise controlled trials and systematic reviews that evaluate patient-related, provider-related, and system-related factors supporting responsible opioid prescribing for chronic non-cancer pain. A scoping review methodology was employed, and six databases were searched. Thirteen systematic reviews and nine controlled trials were included for analysis, and clinical guidelines were reviewed to supplement gaps in the literature. The majority of included studies evaluated provider-related factors, including prescribing behaviours and monitoring for misuse. A smaller number of studies evaluated system-level factors such as regulatory measures and models of healthcare delivery. Studies and guidelines emphasise the importance of careful patient selection for opioid therapy, development of a treatment plan, and cautious initiation and dose escalation. Lower doses are associated with reduced risk of harm and can be efficacious, particularly when used in the context of a multimodal interdisciplinary pain management program. Further research is needed around many elements of responsible prescribing, including instruments to monitor for misuse, and the role of policies and programs.

Pharmacologic Management of Persistent Pain in Cancer Survivors

“…These patients need a full diagnostic workup using a biopsychosocial approach and should be treated congruent with the etiology of pain. Opioids would only be recommended in patients with moderate-severe pain that has not responded to maximum tolerated doses of nonopioid therapies [90,91].…”

Pain management in chronic pancreatitis incorporating safe opioid practices: Challenge accepted

“…There is a need for treatment approaches that are successful in minimizing pain while minimizing the risk of developing OUD. Several pain societies have developed prescription guidelines for patients with non-cancer pain and thus it is important to partner with experienced pain clinics who can provide appropriate attention to patients requiring narcotic therapy[ 28 - 31 ].…”

“…While there is limited data on the opioid prescription guidelines in patients with CP, most experts recommend a one-to-four-week course of low dose opioids (less than 40 morphine milliequivalents) before committing to a long-term opioid therapy for patients with non-cancer pain. This is because higher doses of more than 60 to 90 morphine milliequivalents have been associated with increased risk of dependence and adverse outcomes[ 30 , 31 , 37 ]. Furthermore, there is a dearth of evidence to suggest better efficacy and safety profile of any one opioid over another[ 30 ].…”

“…Additionally, many experts recommend urine drug testing (UDT) prior to starting opioids and eventually for regular monitoring in an effort to curb opioid misuse[ 28 , 30 ]. The United States has mandated prescription monitoring programs (PMP) to track controlled prescriptions which is an efficient tool that can be regularly used by providers to reduce misuse of opioids and other controlled substances[ 28 , 30 , 31 , 37 ]. Close attention can thus be paid to patients with frequent emergency room visits who may be receiving multiple overlapping prescriptions of short course opioids.…”

Development and field testing of primary care screening tools for harms of long-term opioid therapy continuation and tapering to discontinuation: a study protocol

“…If there is a major outlier as a low cutpoint (eg, outcome-specific cutpoints are 3, 7, 8, 9, 11), we may instead choose the Open access tool cutpoint that captures the majority of outcomes (eg, pick 7 rather than 3 as the cutpoint because 3 would yield too many false positives for the other four outcomes). A third case that could occur is that we select the median cutpoint, should the individual cutpoints show a wider range (eg, 3,7,10,13,15); here, 10 might be the tool cutpoint in order to balance false positives and negatives.…”