Opioid Pharmacotherapy for Chronic Non-Cancer Pain in the United States: A Research Guideline for Developing an Evidence-Base

Chapman, C. Richard; Lipschitz, David L.; Angst, Martin S.; Chou, Roger; Denisco, Richard C.; Donaldson, Gary W.; Fine, Perry G.; Foley, Kathleen M.; Gallagher, Rollin M.; Gilson, Aaron M.; Haddox, J. David; Horn, Susan D.; Inturrisi, Charles E.; Jick, Susan S.; Lipman, Arthur G.; Loeser, John D.; Noble, Meredith; Porter, Linda; Rowbotham, Michael C.; Schoelles, Karen M.; Turk, Dennis C.; Volinn, Ernest; Von Korff, Michael R.; Webster, Lynn R.; Weisner, Constance M.

doi:10.1016/j.jpain.2010.02.019

« Previous Next »The Journal of Pain
Volume 11, Issue 9 , Pages 807-829, September 2010

Opioid Pharmacotherapy for Chronic Non-Cancer Pain in the United States: A Research Guideline for Developing an Evidence-Base

C. Richard Chapman
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
- Address reprint requests to C. Richard Chapman, PhD, Pain Research Center, Department of Anesthesiology, University of Utah, 615 Arapeen Drive, Suite 200, Salt Lake City, UT 84108.
David L. Lipschitz
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
Martin S. Angst
- Department of Anesthesiology, Stanford University, Palo Alto, California
Roger Chou
- Internal Medicine and Geriatrics, School of Medicine, Oregon Health & Science University, Portland, Oregon
Richard C. Denisco
- National Institute on Drug Abuse, Division of Epidemiology, Services and Prevention Research, NIH, Bethesda, Maryland
Gary W. Donaldson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
Perry G. Fine
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
Kathleen M. Foley
- Pain & Palliative Care Service, Memorial Sloan Kettering Cancer Center, New York, New York
Rollin M. Gallagher
- Departments of Psychiatry and Anesthesiology and Critical Care, Penn Pain Medicine Center, University of Pennsylvania School of Medicine, and Philadelphia VA Medical Center, Philadelphia, Pennsylvania
Aaron M. Gilson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
J. David Haddox
- Risk Management & Health Policy, Purdue Pharma, Stamford, Connecticut
Susan D. Horn
- Institute for Clinical Outcomes Research (ICOR) and International Severity Information Systems, Inc. (ISIS), Department of Medical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
Charles E. Inturrisi
- Department of Pharmacology, Joan and Sanford I. Weill Medical School of Cornell University, New York, New York
- Pain & Palliative Care Service, Memorial Sloan Kettering Cancer Center, New York, New York
Susan S. Jick
- Department of Epidemiology, Boston University, Boston, Massachusetts
Arthur G. Lipman
- Department of Pharmacotherapy, L.S. Skaggs Pharmacy, University of Utah, Salt Lake City, Utah
John D. Loeser
- Department of Neurological Surgery, University of Washington, Seattle, Washington
Meredith Noble
- ECRI Institute, Plymouth Meeting, Pennsylvania
Linda Porter
- National Institute of Neurological Disorders and Stroke, Systems and Cognitive Neuroscience, National Institutes of Health, Bethesda, Maryland
Michael C. Rowbotham
- Pain Clinical Research Center, University of California San Francisco, San Francisco, California
Karen M. Schoelles
- ECRI Institute, Plymouth Meeting, Pennsylvania
Dennis C. Turk
- Department of Anesthesiology, University of Washington, Seattle, Washington
Ernest Volinn
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
Michael R. Von Korff
- Center for Health Studies Group Health Cooperative, Seattle, Washington
Lynn R. Webster
- Lifetree Pain Clinic, Salt Lake City, Utah
Constance M. Weisner
- Department of Psychiatry, University of California San Francisco, San Francisco, California

published online 29 April 2010.

Abstract

This document reports the consensus of an interdisciplinary panel of research and clinical experts charged with reviewing the use of opioids for chronic noncancer pain (CNCP) and formulating guidelines for future research. Prescribing opioids for chronic noncancer pain has recently escalated in the United States. Contrasting with increasing opioid use are: 1) The lack of evidence supporting long-term effectiveness; 2) Escalating misuse of prescription opioids including abuse and diversion; and 3) Uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events (ADEs) including endocrine dysfunction, immunosuppression and infectious disease, opioid-induced hyperalgesia and xerostomia, overdose, falls and fractures, and psychosocial complications. Chief among the limitations of current evidence are: 1) Sparse evidence on long-term opioid effectiveness in chronic pain patients due to the short-term time frame of clinical trials; 2) Insufficiently comprehensive outcome assessment; and 3) Incomplete identification and quantification of ADEs. The panel called for a strategic interdisciplinary approach to the problem domain in which basic scientists and clinicians cooperate to resolve urgent issues and generate a comprehensive evidence base. It offered 4 recommendations in 3 areas: 1) A research strategy for studying the effectiveness of long-term opioid pharmacotherapy; 2) Improvements in evidence-generation methodology; and 3) Potential research topics for generating new evidence.

Perspective

Prescribing opioids for CNCP has outpaced the growth of scientific evidence bearing on the benefits and harms of these interventions. The need for a strong evidence base is urgent. This guideline offers a strategic approach to creating a comprehensive evidence base to guide safe and effective management of CNCP.

Key words: Opioid pharmacotherapy, chronic pain, evidence-based medicine, guideline, effectiveness, efficacy