European Clinical Practice Recommendations Offer Guidance for Opioid Use in Chronic Pain

doctor writing a prescription
The European Clinical Practice Recommendations were developed to support good decision making and, when needed, appropriate prescribing of opioids for patients of any age with chronic noncancer pain.

Certain opioid medications may be appropriate for select patients with chronic noncancer pain, but careful surveillance is needed to monitor for adverse effects and risks of dependency. A new 2-part, multisociety position paper commissioned by the European Pain Federation (EFIC) and published in the European Journal of Pain provides up-to-date clinical practice recommendations for the use of opioids in the management of chronic noncancer pain.1,2

Clinical practice recommendations in the position paper were developed by 8 scientific societies in conjunction with a patient self-help organization. The recommendations were based on a systematic literature review of research published up to January 2020.

Evidence-based recommendations were developed based on evidence from randomized controlled trials or from observational studies, while Good Clinical Practice (GCP) statements were developed based on either indirect evidence or on case-series, case-control studies, and clinical experience.

In the paper, the committee recommends clinicians work to first optimize established nonpharmacologic therapies and nonopioid analgesics before prescribing an opioid. Nonpharmacologic therapies could include physical exercise, physiotherapy, and psychological treatments.

For patients for whom these established nonpharmacologic treatments or nonopioid analgesics prove ineffective, are poorly tolerated, or are contraindicated, clinicians can then consider an opioid treatment with careful surveillance.

According to GCP statements made in the paper, opioids can be considered for some chronic secondary pain syndromes (eg, chronic pain after spinal cord injury, nondiabetic polyneuropathic pain, chronic radicular pain, or chronic pain in rheumatoid arthritis or Parkinson disease) but not for primary pain syndromes (eg, primary headache, functional somatic disorders, chronic primary musculoskeletal pain syndromes, or chronic pain associated with a mental disorder).

The European Clinical Practice Recommendations advise against prescribing opioids together with benzodiazepines and cautions against combining opioids with gabapentinoids, given the risks for respiratory depression and opioid overdose. The guidelines also state that clinicians could consider the careful use of opioids for patients with liver cirrhosis, but the panel recommends reducing the dose and diligently monitoring the patient.

For patients who experience nausea and vomiting concurrent with opioid use, the guideline states clinicians could consider using antiemetic treatment in some patients at the start of therapy, but clinicians should consider discontinuing this treatment after 2 to 4 weeks.

The guideline panel concluded that “collaboration of medical specialties and all health care professionals is needed for some special populations and clinical situations” to improve the use of opioids in patients with chronic noncancer pain.

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


  1. Häuser W, Morlion B, Vowles KE, et al. European clinical practice recommendations on opioids for chronic noncancer pain – part 1: role of opioids in the management of chronic noncancer pain. Published online March 2, 2021. Eur J Pain. doi:10.1002/ejp.1736
  2. Krčevski Škvarč N, Morlion B, Vowles KE, et al. European clinical practice recommendations on opioids for chronic noncancer pain – part 2: special situations. Published online March 2, 2021. Eur J Pain. doi:10.1002/ejp.1744