Responsible Opioid Prescribing In Chronic Non-Cancer Pain: Part 2 - Guidance

Publication Date: July 1, 2012
Last Updated: March 14, 2022


Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer

Initial Steps of Opioid Therapy

Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (G)
Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (L)
Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. ()
(Evidence: good to fair)
Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (G)

Establishing Diagnosis

Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (G)
Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient; to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (G)
Stratify patients into one of the 3 risk categories – low, medium, or high risk. ()
A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (F)

Establishing Medical Necessity

Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (G)

Establishing Treatment Goals

Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (G)

Assessment of Effectiveness of Opioid Therapy

Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (F)
The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. ()
(Evidence: fair to limited)

Informed Decision-Making

A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (F)

Initial Treatment

Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. ()
(Evidence: fair for short-term effectiveness, limited for long-term effectiveness)
Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (F)
In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (G)

Adherence Monitoring

Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (L)
Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (F)

Monitoring and Managing Side Effects

In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (F)

Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (G)

The Final Phase

Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (F)

Recommendation Grading




Responsible Opioid Prescribing In Chronic Non-Cancer Pain: Part 2 - Guidance

Authoring Organization

Publication Month/Year

July 1, 2012

Last Updated Month/Year

June 21, 2023

Document Type


External Publication Status


Country of Publication


Document Objectives

Guidelines on responsible opioid prescribing provides the recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer.

Target Patient Population

Patient with chronic pain

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospice, Hospital, Long term care, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Counseling, Diagnosis, Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D059350 - Chronic Pain, D059408 - Pain Management, D000701 - Analgesics, Opioid, D009293 - Opioid-Related Disorders


opioids, chronic pain, Opioid Use Disorder

Source Citation

Pain Physician 2012; 15:S67-S116

Supplemental Methodology Resources

Data Supplement