What are the guidelines for prescribing opioids for pain management?

Guidelines for Prescribing Opioids for 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 including addiction, overdose, and death. 1

General Principles for Opioid Prescribing

• Nonopioid therapy is preferred for treatment of chronic pain; opioids should be used only when benefits for pain and function are expected to outweigh risks 1
• When starting opioid therapy for chronic pain, clinicians should establish treatment goals with patients, including realistic goals for pain and function, and consider how opioids will be discontinued if benefits do not outweigh risks 1
• Before initiating opioids, clinicians should determine how functional benefit will be evaluated and establish specific, measurable treatment goals 1
• Clinicians should use the lowest effective dose for the shortest duration consistent with treatment goals 2
• For acute pain, prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids - three days or less will often be sufficient; more than 7 days will rarely be needed 1

Dosing and Medication Selection

• When starting opioid therapy for chronic pain, prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids 1
• If a patient's opioid dosage reaches or exceeds 50 morphine milligram equivalents (MME) per day, implement additional precautions, including increased frequency of follow-up 1
• Avoid increasing opioid dosages to 90 MME or more per day, or carefully justify a decision to increase dosage to this level based on individualized assessment of benefits and risks 1
• For hydrocodone-acetaminophen, the standard dosing recommendation is one to two tablets every 4-6 hours as needed for pain, with a maximum daily limit of 8 tablets 2
• When calculating total daily acetaminophen intake, consider all sources to avoid hepatotoxicity 2

Monitoring and Follow-up

• Evaluate benefits and harms with patients within 1 to 4 weeks of starting opioid therapy for chronic pain or of dose escalation 1
• Evaluate benefits and harms of continued therapy with patients every 3 months or more frequently 1
• Review prescription drug monitoring program data, when available, for high-risk combinations or dosages 1
• If benefits do not outweigh harms of continued opioid therapy, optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids 1

Risk Assessment and Mitigation

• Before starting and periodically during opioid therapy, clinicians should discuss risks and benefits with patients 1
• Avoid concurrent prescribing of opioids and benzodiazepines whenever possible 3
• For patients with opioid use disorder, offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone 1
• Consider offering naloxone when factors that increase risk for opioid overdose are present 1

Special Considerations

• For elderly patients or those with hepatic or renal impairment, consider starting with lower doses and careful titration 2
• Opioid therapy has an important role for acute pain related to severe traumatic injuries, invasive surgeries, and other severe acute pain when nonsteroidal anti-inflammatory drugs and other therapies are contraindicated or likely to be ineffective 2
• For patients already on high-dose opioids (≥90 MME/day), offer the opportunity to reevaluate continued use at high dosages 1

Common Pitfalls to Avoid

• Using opioids as first-line therapy when nonopioid alternatives may be effective 2
• Prescribing opioids on a scheduled basis rather than as-needed for acute pain 2
• Failing to taper opioids if used around the clock for more than a few days 2
• Continuing opioid therapy at this point might represent initiation of long-term opioid therapy, which should occur only as an intentional decision that benefits are likely to outweigh risks 1

Evidence Limitations

• Evidence supports short-term efficacy of opioids in randomized clinical trials lasting primarily 12 weeks or less 1
• Few studies have been conducted to rigorously assess the long-term benefits of opioids for chronic pain with outcomes examined at least 1 year later 1
• No study evaluated long-term (≥1 year) benefit of opioids for chronic pain, but research suggests an increased risk of serious harms that appears to be dose-dependent 4

By following these guidelines, clinicians can improve communication about benefits and risks of opioids for pain management, improve safety and effectiveness of pain treatment, and reduce risks associated with opioid therapy.