New opioid prescribing guidelines for noncancer pain

The first comprehensive, evidence-based clinical practice guideline to help clinicians prescribe opioid analgesics for patients who have chronic noncancer pain was published recently in a collaborative effort between the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM). A panel of pain management experts representing the organizations concluded that opioid pain medications are safe and effective for carefully selected, well-monitored patients.

The APS and the AAPM worked with the Oregon Evidence-based Practice Center at Oregon Health & Science University to review more than 8000 published abstracts and nonpublished studies. Based on the clinical evidence, the panel made 25 specific recommendations for clinicians who care for adults with chronic noncancer pain. They relied on the assumption that prescribers of long-term opioid therapy need clinical skills and knowledge in both the principles of treatment and assessing and managing the risks associated with opioid abuse, addiction, and diversion.

Morphine, oxycodone, oxymorphone, fentanyl, and other opioids traditionally have been used to relieve pain experienced after surgery, resulting from cancer, and experienced at the end of life, it was noted. Opioids currently are used to relieve severe pain caused by chronic low back injury, accident trauma, arthritis, fibromyalgia syndrome, and sickle cell disease.

The guideline advises clinicians to determine whether the patient's pain can be managed with other medications before they initiate long-term opioid therapy. If opioids are deemed appropriate, clinicians are advised to conduct a thorough medical history and examination and assess the potential risk of substance abuse, misuse, or addiction.

The strongest predictor of drug misuse is a personal or family history of alcohol and drug abuse, according to the panel. For patients at higher risk for misuse of opioids, the guideline advises giving patients clear written rules, such as filling prescriptions at 1 pharmacy only and taking random drug tests.

Clinicians are urged to continuously evaluate patients by monitoring their pain intensity, level of functioning, and adherence to prescribed treatments. Ordering periodic drug screens is recommended for patients at risk for aberrant drug behavior.

Regular monitoring is recommended because the therapeutic benefits of opioids can be affected by changes in the underlying pain condition or coexisting disease or in psychological or social circumstances. Because patient self-reports are unreliable, the guideline recommends the use of pill counts, urine drug screening, caregiver interviews, and prescription monitoring data to check for possible abuse.

Other recommendations in the guideline, which appeared in a recent issue of The Journal of Pain, include the following:
• Methadone should be started at low doses and titrated slowly. It should not be used to manage breakthrough pain or as an as-needed drug because it has a long half-life and variable pharmacokinetics.
• Long-term opioid therapy should be discontinued in patients who are known to be diverting their medication or engaging in serious aberrant behaviors.
• For breakthrough pain, as-needed opioids may be prescribed based on an initial and ongoing analysis of therapeutic benefits versus risks.
• Patients who need high dosages of opioids (200 mg/d of morphine or the equivalent) should be evaluated regularly for adverse events.
• Patients should be advised that there is a greater risk of impairment when long-term opioid therapy is started and that if impaired, they should not drive or engage in potentially dangerous work activity.
• Women should be advised that there are risks with long-term opioid therapy during pregnancy and that they should avoid or minimize use of this therapy unless the potential benefits outweigh the risks.

For more information about the opioid prescribing guideline or other APS pain management efforts, visit the organization's Web site at www.ampainsoc.org. Or, contact the APS at American Pain Society, 4700 W. Lake Avenue, Glenview IL 60025; telephone: 847-375-4715; fax: 877-734-8758.