What is the recommended approach for using opioids in chronic pain management?

Recommended Approach for Using Opioids in Chronic Pain Management

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain management, with opioids considered only if expected benefits for both pain and function outweigh risks to the patient. 1

First-Line Therapies for Chronic Pain

• Nonpharmacologic approaches should be used to reduce pain and improve function, including:

  • Exercise therapy 1
  • Cognitive behavioral therapy (CBT) 1
  • Multimodal and multidisciplinary therapies 1

• Nonopioid pharmacologic options should be used when benefits outweigh risks:

  • Acetaminophen (first-line for musculoskeletal pain) 1
  • NSAIDs (first-line for musculoskeletal pain, but with caution regarding GI, renal, and cardiovascular risks) 1, 2
  • Anticonvulsants (gabapentin, pregabalin) for neuropathic pain 1
  • Antidepressants (tricyclics, SNRIs) for neuropathic pain 1

When to Consider Opioids

Opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care due to:

• Small to moderate short-term benefits 1
• Uncertain long-term benefits 1
• Potential for serious harms including overdose, addiction, and death 1

However, opioids may be appropriate in specific circumstances:

• When other therapies have failed to provide adequate pain relief 1
• In cases of serious illness with poor prognosis for return to function 1
• When contraindications to other therapies exist 1
• When clinician and patient agree that comfort is the overriding goal 1

Before Starting Opioid Therapy

• Establish clear treatment goals with patients, including realistic goals for pain and function 1
• Discuss how opioid therapy will be discontinued if benefits do not outweigh risks 1
• Consider risk factors for opioid-related harms:
  • History of substance use disorder 1
  • Mental health comorbidities 1
  • Sleep-disordered breathing 1
  • Concurrent benzodiazepine use 1
  • Advanced age 1

During Opioid Therapy

• Combine opioids with nonpharmacologic therapy and nonopioid pharmacologic therapy to provide greater benefits 1
• Continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks 1
  • Clinically meaningful improvement is defined as a 30% improvement in scores for both pain and function 1
• Monitor for adverse effects:
  • Constipation, nausea, vomiting 2
  • Somnolence, cognitive impairment 2
  • Respiratory depression 2
  • Development of tolerance or dependence 2
• Implement risk mitigation strategies:
  • Regular monitoring through prescription drug monitoring programs 1
  • Urine drug testing 1
  • Opioid treatment agreements 1

Dose Considerations

• Higher opioid dosages are associated with increased overdose risk 1:
  • Dosages of 50-100 MME/day increase risk by factors of 1.9 to 4.6 compared to 1-20 MME/day 1
  • Dosages ≥100 MME/day increase risk by factors of 2.0 to 8.9 1
• When prescribing opioids, use the lowest effective dosage 1

Discontinuation of Opioid Therapy

• Do not abruptly discontinue opioids in physically dependent patients 3, 4
• Implement a patient-specific tapering plan:
  • Reduce dose by small increments (10-25% of total daily dose) 4
  • Proceed with dose-lowering at intervals of 2-4 weeks 3, 4
  • Monitor for withdrawal symptoms and adjust taper accordingly 4
  • Ensure multimodal approach to pain management is in place prior to initiating taper 3

Special Considerations

• For patients with HIV and chronic pain, similar principles apply with careful consideration of opioid risks and benefits 1
• In cases of neuropathic pain, a combination of morphine and gabapentin may be considered for potential additive effects 1
• For osteoarthritis, tramadol may be considered for up to 3 months to decrease pain and improve function 1

Common Pitfalls to Avoid

• Failing to establish clear treatment goals before initiating opioid therapy 1
• Not having an "exit strategy" for discontinuation if therapy is unsuccessful 1
• Prescribing opioids without considering risk factors for adverse outcomes 1
• Abrupt discontinuation of opioids, which can lead to withdrawal, uncontrolled pain, and potential suicide 3
• Neglecting to combine opioids with other pain management modalities 1