Population: Adults with chronic noncancer pain outside of palliative and end-of-life care.
Organizations
CDC 2016, ICSI 2017
Recommendations
Evaluation (ICSI)
–Use validated tools to assess patient’s functional status, pain, and quality of life.
–Assess for current or prior exposure to opioids and consider checking prescription drug monitoring program data before prescribing opioids.
–Assess for mental health comorbidities in patients with chronic pain.
–Screen all patients with chronic pain for substance use disorders.
–Before initiating opioids for chronic pain, seek a diagnostic cause of the pain and document objective findings on physical exam.
Management
–Prefer nonpharmacologic therapy and nonopioid medications for chronic pain.
–Prescribe NSAIDs and acetaminophen for dental pain. (ICSI)
–Use opioid therapy for both pain and function only if the anticipated benefits outweigh the risks.
–Establish treatment goals, including goals for pain and function, before starting opioid therapy for chronic pain. Plan how opioid therapy will be discontinued if benefits do not outweigh the risks.
–Discuss with patients the risks and benefits of opioid therapy before starting opioids and periodically during therapy.
–Incorporate cognitive behavioral therapy or mindfulness-based stress reduction and exercise/physical therapy to pharmacologic therapy in chronic pain patients. (ICSI)
–When starting opioid therapy, use immediate-release opioids, and prescribe the lowest effective dose. (CDC)
–Reserve long-acting opioids for patients with opioid tolerance and in whom prescriber is confident of medication adherence. (ICSI)
–Carefully reassess benefits and risks when increasing daily dosage to >50 morphine milligram equivalents.
–Avoid increasing daily dosage to >90–100 morphine milligram equivalents or carefully justify such doses.
–Reassess efficacy within 4 wk of starting opioid therapy for chronic pain and consider discontinuing opioids if benefits do not outweigh risks.
Surveillance
–Evaluate risks of opioid-related harms.
–Advise patients who are initiating opioids or who have their opioid dose increased not to operate heavy machinery, drive a car, or participate in any activity that may be affected by the sedating effect of opioids.
–Prescribe naloxone emergency kit when patients have an increased risk of opioid overdose especially in patients who are taking ≥50 morphine milligram equivalents per day or concurrently using a benzodiazepine.
–Review prescription drug monitoring program data frequently.
–Obtain periodic urine drug testing to monitor diversion.
–Avoid concurrent opioid and benzodiazepine therapy whenever possible.
–Assess geriatric patients for their fall risk, cognitive impairment, respiratory function, and renal/hepatic impairment prior to initiation of opioids. (ICSI)
–Offer or arrange for medication-assisted treatment for patients with opioid use disorders (eg, buprenorphine or methadone).
Sources
–MMWR Recomm Rep. 2016;65(1):1-49.
–https://www.cdc.gov/drugoverdose/pdf/guidelines_at-a-glance-a.pdf
–Hooten M et al. Pain: Assessment, Non-opioid Treatment Approaches and Opioid Management. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2016:160.