The American Pain Society and the American Academy of Pain Publish Guidelines for Prescribing Opioids

The American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) has published the first comprehensive, evidence-based clinical practice guideline to assist clinicians in prescribing potent opioid pain medications for patients with chronic non-cancer pain. The guideline appears in the February issue of The Journal of Pain.

To create this guideline, researchers reviewed more than 8,000 published abstracts and nonpublished studies to assess clinical evidence on which the new recommendations are based.

"This guideline was a true multidisciplinary effort that sought to address in a balanced manner the many challenging issues that clinicians face with regard to when and how to prescribe opioids for chronic noncancer pain," said principal investigator Roger Chou, MD, Oregon Evidence-Based Practice Center, Oregon Health & Science University, Portland, Oregon.

"A key part of this process was performing a comprehensive literature review to inform the recommendations -- though an important take-home message is that even though the recommendations represent the best judgment of the panel based on the currently available literature, there is still a lot of research that needs to be done."

The expert panel concluded that opioid pain medications are safe and effective for carefully selected, well-monitored patients with chronic non-cancer pain. They made 25 specific recommendations and achieved unanimous consensus on nearly all.

Prior to initiating chronic opioid therapy, the guideline advises clinicians to determine if the pain can be treated with other medications. If opioids are appropriate, the clinician should conduct a thorough medical history and examination, and assess potential risk for substance abuse, misuse or addiction.

A key recommendation urges clinicians to continuously assess patients on chronic opioid therapy by monitoring pain intensity, level of functioning, and adherence to prescribed treatments. Periodic drug screens should be ordered for patients at risk for aberrant drug behaviour.

Other recommendations in the practice guideline include:
· Methadone: Use of methadone for pain management has increased dramatically but few trials have evaluated its benefits and harms for treatment of chronic non-cancer pain. Methadone, therefore, should be started at low doses and titrated slowly. Because of its long half-life and variable pharmacokinetics, the panel recommends methadone not be used to treat breakthrough pain or as an as-needed medication.
· Abusers: Chronic opioid therapy must be discontinued in patients known to be diverting their medication or in those engaging in serious aberrant behaviours.
· Breakthrough Pain: As-needed opioids can be prescribed based on initial and ongoing analysis of therapeutic benefit versus risk.
· High Doses: Patients who need high doses of opioids should be evaluated for adverse events on an ongoing basis, and clinicians should consider rotating pain medications when patients experience intolerable side effects or inadequate benefit despite appropriate dose increases.
· Pregnancy: Clinicians should counsel women about risks of opioids in pregnancy and encourage minimal or no use of chronic opioid therapy unless potential benefits outweigh risks.

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