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 after a systematic review of the evidence.

Key words: Clinical practice guideline, opioids, opioid analgesics, risk assessment, monitoring, chronic pain

1 Oregon Evidence-based Practice Center, Department of Medicine, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon

2 Pain Management Center, Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

3 Pain Research Center, Department of Anesthesiology, University of Utah, Salt Lake City, Utah

4 Pacific Pain Medicine Consultants, Encinitas, California

5 Division of Pain Medicine, Department of Anesthesia and Critical Care, Massachusetts General Hospital, Boston

6 Seattle Cancer Care Alliance, Seattle, Washington

7 Pain Management Clinic, Kaiser Permanente Northwest, Portland, Oregon

8 School of Medicine, Neurological Surgery and Anesthesiology, University of Miami, Miami, Florida

9 Pain and Palliative Care Service, Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, New York

10 Samuel S. Stratton Department of Veterans Affairs Medical Center, and Albany College of Pharmacy & Health Sciences, Albany, New York

11 Pain and Policy Studies Group, Paul P. Carbone Comprehensive Cancer Center, University of Wisconsin, Madison

12 Epidemiology and Prevention for Injury Control (EPIC) Branch, California Department of Health Services, Sacramento, California (retired 2005)

13 New York Headache Center, New York, New York

14 Section of General Internal Medicine, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, Connecticut

15 Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, New York

16 Laboratory of Molecular Neuropharmacology, Department of Molecular Pharmacology and Chemistry, Memorial Sloan-Kettering Cancer Center, New York, New York

17 Department of Pain Medicine and Palliative Care, Beth Israel Medical Center, New York, New York

18 School of Medicine, Division of Bioethics, University of California Davis

19 School of Medicine and Public Health, University of Wisconsin, Madison

20 Pain and Emergency Medicine Institute, Beth Israel Medical Center, New York, New York

21 Department of Physiological Nursing, University of California, San Francisco

Address reprint requests to Dr Roger Chou, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239.

Editor's Note: The American Pain Society and the American Academy of Pain Medicine present this first of 3 articles 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.

PII: S1526-5900(08)00831-6

doi:10.1016/j.jpain.2008.10.008

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