The Journal of Pain
Volume 10, Issue 2 , Pages 147-159.e15, February 2009

Research Gaps on Use of Opioids for Chronic Noncancer Pain: Findings From a Review of the Evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline

  • Roger Chou

      Affiliations

    • The Oregon Evidence-Based Practice Center, Department of Medicine, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon
    • Corresponding Author InformationAddress reprint requests to Dr Roger Chou, 3181 SW Sam Jackson Park Road, Mail code BICC, Portland, OR 97239.
    • ,
  • Jane C. Ballantyne

      Affiliations

    • Division of Pain Medicine, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
    • ,
  • Gilbert J. Fanciullo

      Affiliations

    • Pain Management Center, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
    • ,
  • Perry G. Fine

      Affiliations

    • Pain Research Center, Department of Anesthesiology, University of Utah, Salt Lake City, Utah
    • ,
  • Christine Miaskowski

      Affiliations

    • Department of Physiological Nursing, School of Nursing, University of California, San Francisco, California

Abstract 

Chronic noncancer pain is common and use of opioids is increasing. Previously published guidelines on use of opioids for chronic noncancer pain have been based primarily on expert consensus due to lack of strong evidence. We conducted searches on Ovid MEDLINE and the Cochrane databases through July 2008 to identify studies that addressed one or more of 37 Key Questions that a multidisciplinary expert panel identified as important to be answered to generate evidence-based recommendations on the use of opioids for chronic noncancer pain. A total of 14 systematic reviews, 38 randomized trials not included in a previously published systematic review, and 13 other studies met inclusion criteria. Almost all of the randomized trials of opioids for chronic noncancer pain were short-term efficacy studies. Critical research gaps on use of opioids for chronic noncancer pain include: lack of effectiveness studies on long-term benefits and harms of opioids (including drug abuse, addiction, and diversion); insufficient evidence to draw strong conclusions about optimal approaches to risk stratification, monitoring, or initiation and titration of opioid therapy; and lack of evidence on the utility of informed consent and opioid management plans, the utility of opioid rotation, the benefits and harms specific to methadone or higher doses of opioids, and treatment of patients with chronic noncancer pain at higher risk for drug abuse or misuse.

Perspective

Currently, clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to be set to address these critical research needs if the care of patients with chronic noncancer pain is to improve.

Key words: Analgesics, opioid, pain, evidence-based medicine, risk assessment, drug monitoring, treatment outcomes, harms, research gaps, systematic review

 

 Editor's Note: The American Pain Society and the American Academy of Pain Medicine present this final article in this 3-part report as a guideline for opioid treatment of noncancer pain.

 This article is based on research conducted at the Oregon Evidence-based Practice Center, with funding from the American Pain Society (APS). The authors are solely responsible for the content of this article and the decision to submit for publication. No statement in this article should be construed as an official position of the APS or the American Academy of Pain Medicine. The authors have no known or potential conflicts of interest to declare.

PII: S1526-5900(08)00830-4

doi:10.1016/j.jpain.2008.10.007

The Journal of Pain
Volume 10, Issue 2 , Pages 147-159.e15, February 2009

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