Chronic Pain Management with Opioids
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain, with opioids reserved only for cases where benefits for both pain and function are expected to outweigh significant risks. 1
First-Line Approaches (Before Considering Opioids)
Nonpharmacologic Therapies
- Physical therapy - Should be the cornerstone of treatment, especially for musculoskeletal pain 2
- Cognitive behavioral therapy (CBT) - Addresses pain catastrophizing and improves coping strategies 2
- Exercise therapy - Improves function and reduces pain intensity 1
- Weight management - For patients where excess weight contributes to pain 2
Nonopioid Pharmacologic Options
- Acetaminophen - Up to 3000-4000mg daily for scheduled use 2
- NSAIDs - Oral or topical, at lowest effective dose for shortest duration 2
- SNRIs (duloxetine) - Provides dual benefit for pain and mood disorders 2
- Anticonvulsants (pregabalin, gabapentin) - Particularly for neuropathic pain 1
Opioid Therapy Decision Algorithm
Step 1: Risk-Benefit Assessment
- Determine if patient has:
- Active cancer, palliative care needs, or end-of-life care (opioids may be appropriate)
- Conditions where opioids are unlikely to help (headache, fibromyalgia)
- Contraindications to other therapies
- Failed adequate trials of non-opioid approaches
Step 2: Pre-Initiation Requirements
- Check prescription drug monitoring program (PDMP) 1
- Conduct urine drug screening 1
- Establish specific, measurable treatment goals for pain and function 1
- Discuss risks, including overdose, addiction, and side effects 1
- Create an "exit strategy" for discontinuation if benefits don't outweigh risks 1
Step 3: Prescribing Protocol
- Start with immediate-release rather than extended-release/long-acting opioids 1
- Begin with lowest effective dose 1
- Use caution when increasing dosage to ≥50 morphine milligram equivalents (MME)/day 1
- Avoid dosages ≥90 MME/day or carefully justify such decisions 1
- Avoid concurrent benzodiazepine prescription whenever possible 1
Step 4: Monitoring
- Evaluate benefits and harms within 1-4 weeks of starting therapy 1
- Continue only if there is clinically meaningful improvement in pain and function 1
- Reassess every 3 months or more frequently 1
- Check PDMP data at each prescription renewal 1
- Conduct periodic urine drug testing 1
Discontinuation of Opioid Therapy
- Never discontinue opioids abruptly in physically dependent patients 3, 4
- Implement a patient-specific tapering plan:
- Monitor for withdrawal symptoms (restlessness, lacrimation, rhinorrhea, yawning, perspiration, chills, myalgia) 3, 4
- If withdrawal symptoms emerge:
Special Considerations
High-Risk Patients
- Age ≥69: Higher risk of adverse effects 2
- Psychiatric comorbidities: Bipolar disorder increases risk of misuse 2
- Sleep-disordered breathing: Increased risk of respiratory depression 1
- Renal/hepatic impairment: Altered drug metabolism increases risk 1
- Concurrent benzodiazepines: Dramatically increases overdose risk 1
Opioid Use Disorder Management
- Offer evidence-based treatment (medication-assisted treatment with buprenorphine or methadone) 1
- Consider referral to addiction specialist 1
Efficacy and Safety Concerns
- In a 13-month trial, 90% of patients on opioids experienced at least one adverse event, with 34% withdrawing from treatment 1
- Limited evidence supports long-term effectiveness of opioids for chronic pain 1
- Risk of overdose increases in dose-dependent manner:
The evidence clearly shows that while opioids may provide short-term pain relief, their long-term effectiveness is questionable, and they carry significant risks of adverse effects, dependence, and overdose. A structured, cautious approach that prioritizes non-opioid therapies and carefully monitors patients when opioids are deemed necessary is essential for optimizing outcomes and minimizing harm.