When is the use of opioids warranted for chronic pain relief?

When Opioids Are Warranted for Chronic Pain Relief

Opioids should only be considered for chronic pain when nonopioid and nonpharmacologic therapies have been ineffective, when benefits for pain and function are expected to outweigh risks, and in specific clinical contexts where patient comfort is the overriding goal. 1

Primary Decision Algorithm for Opioid Use in Chronic Pain

1. First-line approaches (must be tried first):

   • Nonpharmacologic therapies (exercise therapy, cognitive behavioral therapy, physical therapy)
   • Nonopioid pharmacologic therapies (NSAIDs, acetaminophen, anticonvulsants, SNRIs)

2. Consider opioids only when:

   • Patient has moderate to severe pain with functional impairment
   • First-line therapies have failed to provide adequate relief
   • Benefits for both pain and function are anticipated to outweigh risks
   • A clear treatment plan with goals and exit strategy is established

3. Specific clinical contexts where opioids may be appropriate:

   • Serious illness with poor prognosis for functional recovery
   • Contraindications to other therapies exist
   • Clinician and patient agree that comfort is the primary goal
   • Pain is causing significant functional impairment despite other interventions

When Opioids Are NOT Warranted

Opioids are unlikely to be appropriate for:

• Headache disorders
• Fibromyalgia
• Mild to moderate pain that responds to other therapies
• As first-line therapy (except in specific contexts noted above)
• When risks outweigh potential benefits
• When used as monotherapy without integration of nonpharmacologic approaches

Risk Assessment and Monitoring Requirements

Before initiating opioid therapy, clinicians must:

1. Establish treatment goals for pain and function
2. Discuss benefits, risks, and alternatives with the patient
3. Assess risk for opioid-related harms (history of substance use disorder, mental health conditions)
4. Create an opioid patient-provider agreement 1
5. Plan for regular monitoring (urine drug testing, prescription monitoring program checks)

Monitoring and Continuation Criteria

Opioid therapy should only be continued if:

• Clinically meaningful improvement in pain and function is documented
• Benefits continue to outweigh risks
• No serious adverse events or concerning behaviors occur
• Regular reassessment occurs (every 3 months or more frequently) 1

Important Caveats and Pitfalls

• Dose dependence: Risk of harm increases with higher doses; avoid exceeding 50 MME/day when possible, and carefully justify doses ≥90 MME/day 1
• Addiction risk: Patients with personal or family history of substance abuse require intensive monitoring 2
• Overdose prevention: Naloxone should be readily available for high-risk patients 1
• Drug interactions: Be vigilant about potential interactions with other medications 1
• Avoid abrupt discontinuation: Taper gradually when discontinuing to prevent withdrawal

Evidence Quality Considerations

The evidence for long-term effectiveness of opioids in chronic non-cancer pain is limited:

• Weak evidence suggests that morphine and transdermal fentanyl may decrease pain and improve function for periods >6 months 3
• Limited evidence exists for the most commonly prescribed opioids (oxycodone, hydrocodone) 3
• Many patients discontinue opioid therapy due to adverse effects or insufficient pain relief 3

Special Populations

For patients living with HIV who have chronic pain:

• NSAIDs are recommended as first-line agents for musculoskeletal pain
• Opioids should be considered only after first-line therapies fail and when moderate to severe pain and functional impairment are present 1

The 2022 CDC guideline emphasizes that opioid therapy has an important role for pain related to severe traumatic injuries, invasive surgeries with moderate to severe postoperative pain, and other severe pain when NSAIDs and other therapies are contraindicated or likely ineffective 1. However, for most chronic pain conditions, the risks of long-term opioid therapy often outweigh the benefits, making nonopioid approaches the preferred treatment strategy.