Are opioids indicated for chronic pain management?

Opioids for Chronic Pain Management

Opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care, given their small to moderate short-term benefits, uncertain long-term benefits, and potential for serious harms. 1, 2

First-Line Treatments for Chronic Pain

• Nonpharmacologic therapies:

  • Cognitive-behavioral therapy (CBT)
  • Exercise and physical activity
  • Physical therapy
  • Occupational therapy
  • Heat/cold therapy
  • Relaxation techniques
  • Massage therapy
  • Transcutaneous Electrical Nerve Stimulation (TENS)
  • Mindfulness-Based Stress Reduction

• Nonopioid pharmacologic therapies:

  • NSAIDs and acetaminophen
  • Anticonvulsants (gabapentin, pregabalin)
  • SNRIs (duloxetine, milnacipran)
  • Tricyclic antidepressants
  • Topical agents (lidocaine)

When Opioids May Be Considered

Opioids may be appropriate in specific circumstances:

1. When expected benefits for both pain and function outweigh risks
2. When alternative treatments have not provided adequate analgesia or are not expected to provide adequate analgesia 3
3. In certain clinical contexts such as serious illness with poor prognosis for functional return
4. When contraindications exist to other therapies
5. When clinician and patient agree that patient comfort is the overriding goal 1

Opioid Therapy Implementation Protocol

If opioids are prescribed for chronic pain:

1. Before starting:

   • Establish clear treatment goals for pain and function
   • Discuss realistic benefits, risks, and alternatives
   • Create an opioid treatment agreement
   • Check prescription drug monitoring program (PDMP)
   • Conduct urine drug testing
   • Perform comprehensive risk assessment

2. Initial prescription:

   • Start with immediate-release formulations (not extended-release)
   • Use lowest effective dose
   • Combine with nonpharmacologic and nonopioid pharmacologic therapies 1, 2

3. Monitoring:

   • Evaluate benefits and harms within 1-4 weeks of starting therapy
   • Continue only if there is clinically meaningful improvement in pain and function (defined as 30% improvement in scores) 1
   • Reassess every 3 months or more frequently
   • Use caution when increasing dosage to ≥50 MME/day
   • Avoid dosages ≥90 MME/day or carefully justify their use 2

4. Discontinuation considerations:

   • Side effects (90% of patients experience at least one opioid-related adverse event) 1
   • Lack of efficacy
   • Aberrant drug behavior

Common Pitfalls and Caveats

• Overdependence on opioids: Evidence for long-term benefit of opioids is weak, while risks are substantial 1, 2
• Inadequate risk assessment: Failure to identify patients at high risk for misuse or overdose
• Insufficient monitoring: Not regularly assessing for improvement in function, side effects, or aberrant behaviors
• Concurrent benzodiazepine use: Should be avoided whenever possible due to increased overdose risk 2
• Dose escalation without benefit: Continuing to increase dose when no functional improvement is seen
• Failure to use multimodal approach: Opioids should always be combined with nonpharmacologic and nonopioid pharmacologic therapies 1
• Inadequate treatment of comorbid conditions: Depression, anxiety, and sleep disorders can worsen pain and reduce opioid efficacy

Special Considerations for Specific Pain Conditions

• Headache and fibromyalgia: Expected benefits of initiating opioids are unlikely to outweigh risks regardless of previous therapies used 1
• Neuropathic pain: Other medications (tricyclics, selected anticonvulsants, or transdermal lidocaine) generally recommended over opioids 1
• Musculoskeletal pain: Physical therapy and exercise often more beneficial long-term than opioids

The evidence clearly shows that while opioids may provide short-term pain relief for some patients with chronic pain, their long-term effectiveness is questionable, and they carry significant risks of adverse effects, dependence, and overdose. A thoughtful, cautious approach that prioritizes safer alternatives is warranted in most cases of chronic non-cancer pain.