Opioid Prescribing Guidelines for Chronic, Non-Cancer Pain

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Experts in a variety of medical fields were brought in by ASIPP to review available evidence and create recommendations.
Experts in a variety of medical fields were brought in by ASIPP to review available evidence and create recommendations.

The American Society of Interventional Pain Physicians (ASIPP) has issued updated opioid prescribing guidelines for the management of patients with chronic, non-cancer pain. The guidelines were published in Pain Physician.1

Experts in a variety of medical fields were brought in by ASIPP to review available evidence and create recommendations “to provide a systematic and standardized approach to this complex and difficult arena of practice, while recognizing that every clinical situation is unique.” Each recommendation is graded based on the quality and strength of evidence. For example, a recommendation with an evidence level of I is considered strong because it was made based on evidence from multiple relevant high quality randomized controlled trials. In contrast, a statement with an evidence level of V would indicate that the recommendation was based on opinion or by consensus of a large group of clinicians and/or scientists.

When initiating opioid therapy, the panel recommends the following:

  • Comprehensive assessment and documentation (ie, general medical history, psychiatric status, substance use history) (Evidence: Level I; Strong)
  • Screen for opioid abuse to identify abusers (Evidence: Level II-III; Moderate)
  • Implement Prescription Drug Monitoring Programs (PDMPs) which provide patterns of prescription use (Evidence: Level I-II; Moderate to strong)
  • Implement urine drug testing (UDT) at the start, use for adherence monitoring or abuse detection (Evidence: Level II; Moderate)
  • If available, establish physical and psychological diagnoses before starting treatment (Evidence: Level I; Strong)
  • Consider appropriate imaging, physical diagnosis, and psychological status before establishing therapy with opioids (Evidence: Level II; Moderate)
  • Medical necessity should be established before starting or maintaining opioid therapy (Evidence: Level I; Strong)
  • Stratify patients based on risk (Evidence: Level I-II; Moderate)
  • Establish treatment goals (ie, pain relief, functional improvement) (Evidence: Level I-II; Moderate)

Once the decision has been made to initiate opioid therapy, the panel recommends the following:

  • Before initiating or maintaining therapy, an opioid agreement should be made and followed by clinician and patient to reduce misuse and abuse (Evidence: Level III; Moderate)
  • Initiate therapy with low doses and short-acting drugs with appropriate monitoring (Evidence: Level II; Moderate)
  • Low dose: 40 MME (morphine milligram equivalent); Moderate dose: 41–90 MME; High dose: >91 MME (Evidence: Level II; Strong)
  • Do not use long-acting opioids as initial therapy (Evidence: Level I; Strong)
  • Methadone use should be limited to patients who have failed other opioid therapies and only by those specifically trained in prescribing it within FDA approved indications (Evidence: Level I; Strong)
  • Educate patients on efficacy, adverse effects, and limitations of long-term opioid therapy (Evidence: Level I; Strong)
  • Evidence of efficacy similar for long-acting and short-acting opioids; increased side effects with long-acting agents (Evidence: Level I-II; Moderate to strong)
  • Periodic assessment of pain relief and/or functional improvement of ≥ 30% without side effects is recommended (Evidence: Level II; Moderate)
  • Long-acting opioids, high doses are only recommended in specific circumstances (ie, severe, intractable pain not amenable to short-acting agents) (Evidence: Level I; Strong)

When monitoring for adherence and adverse effects, clinicians should do the following:

  • UDT, PDMPs provide evidence of those who are non-compliant or are abusing medications or illicit drugs (Evidence: Level I-II; Moderate to strong)
  • For patients on methadone: perform electrocardiogram before initiation, at 30 days, after dose increases, then yearly thereafter (Evidence: Level I; Strong)
  • Monitor for constipation, other side effects; discontinue opioids when indicated (Evidence: Level I; Strong)
  • With proper adherence monitoring, chronic opioid therapy may be continued in well-selected populations, in conjunction with or after failure of other treatments, as long as there is improvement in physical and functional status and minimal side effects (Evidence: Level I-II; Moderate)
  • Opioid therapy should be discontinued if there is a lack of response, adverse effects, or abuse with rehabilitation (Evidence: Level III; Moderate)

In conclusion, the panel states that “chronic opioid therapy should be provided only to patients with proven medical necessity and stability with improvement in pain and function, independently or in  conjunction  with  other  modalities  of  treatments  in  low  doses  with  appropriate  adherence monitoring  and  understanding of adverse events.”

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Reference

  1. Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2017;20(2S):S3-S92.
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