Prescription of Opioids for Chronic Non-Cancer Pain

Publication Date: December 26, 2023
Last Updated: January 2, 2024

Initial Steps of Opioid Therapy

Comprehensive evaluation of pain history, medical history, psychosocial history, functional assessment, and appropriate consultations are recommended prior to initiation of opioid therapy. (I, Strong)
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Review of Prescription Drug Monitoring Program (PDMP) data prior to initiating any/all controlled substance prescriptions and periodically or as mandated by regulations during treatment in order to provide information on patterns of prescribing from all providers registered with the system. (moderate to strong evidence level) (II, Strong)
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Risk stratification as part of patient management is essential for opioid and controlled substance medication management. (IV, Moderate)
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Urine drug monitoring (UDM) should be implemented at the initiation of opioid therapy and conducted periodically for monitoring therapeutic compliance as per available guidance referential to mode and frequency of testing. (II, Strong)
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Prior to starting opioid therapy, clinicians should discuss the realistic benefits, and known risks with patients; should establish clear treatment goals for pain and/or function and should consider – and discuss - how opioid therapy will be discontinued if benefits do not outweigh risks. (I, Strong)
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It is essential to establish goals of opioid therapy related to pain relief, improvement in function if and as possible, improvement in quality of life, and a plan for opioid tapering and cessation if and when meaningful, realistic improvement is not achieved from opioid therapy. (I, Strong)
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A controlled substance agreement that is detailed with each item, including safe storage and disposal, and initialed and signed by the patient is essential prior to initiating therapy. (I, Strong)
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Once medical necessity is established, opioid therapy may be initiated using low doses and short-acting drugs, with appropriate monitoring to provide effective relief and avoid side effects. (strength moderate to strong) (II, Moderate)
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Long-acting opioids should not be utilized for the initiation of opioid therapy. (I, Strong)
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Methadone is recommended for use after failure of other opioid therapies only if EKG and evaluation of QT intervals and drug interactions have been conducted and evaluated; commencing with low doses, with dose adjustments with repeat EKG performed at least 6-12 months thereafter. Only clinicians with specific training in methadone prescribing, use, and risk management should offer this agent for treatment of noncancer pain that is resistant to effect(s) of other opioids. (I, Strong)
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Assessment of Effectiveness of Opioid Therapy

Physicians should evaluate meaningful benefit (i.e., least 30% benefit in pain and/or function) produced by opioid treatment and should ensure that opioid therapy does not incur aberrant behaviors and/or adverse effects. (II, Moderate)
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Clinicians must understand the effectiveness, viability, limitations, adverse consequences, and relative value (versus burden/risk) of long-term opioid therapy in chronic non-cancer pain. (I, Strong)
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The evidence of effectiveness is similar for short-acting and long-acting opioids, with increased incidence and prevalence of adverse consequences evidenced with the use of long-acting opioids. (II, Moderate)
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The administration of high doses of long-acting opioids is recommended in limited circumstances wherein severe intractable pain is not responsive or mitigated by short-acting opioids or moderate doses of long-acting opioids. (II, Moderate)
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Tapering or weaning processes must be initiated slowly after appropriate criteria have been met and should entail slow tapering of the dosage across a specified period of time. Reinstitution of opioid therapy can be considered when such treatment is deemed medically necessary if the patient’s behavior and pattern of drug use are shown to be stable, and if results of at least two consistent urine drug tests are negative (for opioids and/or illicit drugs). (II, Moderate)
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Monitoring Adherence and Side Effects

Adherence monitoring to assess and sustain appropriate use must be instituted at proper intervals, as based on risk stratification and indication(s) of other issues that may be regarded as negatively influencing therapeutic compliance. (II, Moderate)
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It is essential to monitor and manage side effects appropriately; such management may include discontinuation of opioids if indicated. (I, Strong)
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Bowel function must be closely monitored to assess opioid-induced constipation, and a bowel regimen should be initiated as soon as deemed necessary. (I, Strong)
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Final Phase

Chronic opioid therapy may be maintained, with continuous adherence monitoring, and modified at any time during his phase, in conjunction with - or after failure of - other modalities of pain care, for those patients demonstrating reasonable improvement in physical and functional status, and minimal adverse effects. (II, Moderate)
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Chronic opioid therapy should be monitored for (burdensome and adverse) side effects, and these side effects should be managed appropriately. (I, Strong)
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Recommendation Grading

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.

Overview

Title

Prescription of Opioids for Chronic Non-Cancer Pain

Authoring Organization

Publication Month/Year

December 26, 2023

Last Updated Month/Year

February 19, 2024

Document Type

Guideline

Country of Publication

US

Document Objectives

We herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Treatment, Management

Keywords

opioids, Prescribing of Opioids, non cancer pain, appropriate prescribing

Source Citation

Manchikanti L, Kaye AM, Knezevic NN, Giordano J, Applewhite MK, Bautista A, Soin A, Blank SK, Sanapati MR, Karri J, Christo PJ, Abd-Elsayed A, Kaye AD, Calodney A, Navani A, Gharibo CG, Harned M, Gupta M, Broachwala M, Sehgal N, Kaufman A, Wargo B, Solanki DR, Hsu ES, Limerick G, Dennis A, Swicegood JR, Slavin K, Snook L, Pasupuleti R, Kosanovic R, Justiz R, Barkin R, Atluri S, Shah S, Pampati V, Helm Ii S, Grami V, Myckowiak V, Galan V, Singh V, Manocha V, Hirsch JA. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician. 2023 Dec;26(7S):S7-S126. PMID: 38117465.