GLENVIEW, Illinois—A new guideline issued by the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) aims to curb opioid abuse, addiction, and diversion, and to  minimize side effects among patients with chronic noncancer pain by improving prescribing.

Published in The Journal of Pain,1 the new guideline advises doctors to:
  • determine if the pain can be treated with other medications prior to initiating chronic opioid therapy,
  • conduct a thorough medical examination to assess risk for substance abuse, misuse or addiction if opioids are indicated, and
  • remember that the strongest predictors of opioid abuse are personal or family history of alcohol or drug abuse.

Give patients written rules for opioid use

“For patients at higher risk for misuse of opioids, the guideline advises giving patients clear written rules, such as filling prescriptions at one pharmacy only, taking random drug tests, making regular physician visits, and locking their medications at home."—Gilbert J. Fanciullo, MD

"For patients at higher risk for misuse of opioids, the guideline advises giving patients clear written rules, such as filling prescriptions at one pharmacy only, taking random drug tests, making regular physician visits, and locking their medications at home," said Gilbert J. Fanciullo, MD, a panel co-chair and director, Section of Pain Medicine, Dartmouth Hitchcock Medical Center, in a written press release.

The vigilance does not stop there. Prescribing clinicians must continuously assess patients on chronic opioid therapy by monitoring pain intensity, level of functioning and adherence to prescribed treatments. Doctors should also order periodic drug screens for patients at risk for aberrant drug behavior, and chronic opioid therapy must be discontinued in patients known to be diverting their medication or in those engaging in serious aberrant behaviors.

Monitor opioid users regularly

"Regular monitoring of chronic opioid therapy patients is warranted because the therapeutic benefits of these medications are not static and can be affected by changes in the underlying pain condition, coexisting disease, or in psychological or social circumstances," said Dr. Fanciullo. "For patients at low risk for adverse outcomes and on stable doses of opioids, monitoring at least once every three to six months is sufficient, but weekly monitoring is justifiable for those at high risk for abuse and other adverse events."

To develop the new guideline, the APS, AAPM and the Oregon Evidence-based Practice Center at Oregon Health and Science University reviewed more than 8,000 published abstracts and non-published studies on the use of opioids to treat chronic noncancer pain.

The guideline also reflects on the use of methadone for pain management, but few trials have evaluated its benefit/risk profile for the treatment of chronic noncancer pain. Methadone should be started at low doses and titrated slowly. It should not be used to treat breakthrough pain or as an as-needed medication.

Patients who need high doses of opioids (200 mg daily of morphine or equivalent) should be evaluated for adverse events on an ongoing basis, the guideline states. Physicians should consider rotating pain medications when patients experience intolerable side effects or inadequate benefit despite appropriate dose increases.

References

1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy chronic noncancer pain. The Journal of Pain. 2009; 10:113-130.