Background: There is increasing concern about the personal and public safety of prescription opioids for chronic pain. In the United States (US), opioid prescription rates, emergency room visits, and mortality rates have risen sharply in the last 10years. However, it is not clear that opioids are effective for chronic pain. There are high levels of adverse effects and psychiatric comorbidities among patients using chronic opioids. Consistent adherence to evidence-based best practices would significantly improve patient safety.

Objectives: 1. To review and assess the literature on the relative effectiveness, risks and benefits of opioid medications for chronic pain. 2. To review and assess the literature on management of opioid use for chronic pain. 3. To suggest a research agenda to support more effective chronic pain management.

Methods: We searched The Cochrane Library, other databases, and evidence generated to support guidelines for systematic reviews on opioid use in chronic pain. We then classified and critiqued the evidence. We also reviewed the evidence and behavior change techniques used to support safe prescribing and pain management at Kaiser Permanente Medical Centers.

Results: Most literature in this area consists of observational studies that are low quality according to the GRADE system. Virtually all studies lasted less than 3 months, which is not considered chronic. Retrospective cohort studies described high levels of psychiatric comorbidities and adverse effects of opioids. Pilot studies have shown wide variance in opioid prescribing patterns, which seem stable over time despite educational interventions.

Conclusion: The effectiveness, efficacy and safety of opioids for chronic pain are not clear based on current evidence. Increasing use of chronic opioids is associated with public health problems. More consistent, evidence-based prescribing patterns would improve effectiveness and safety. Research designs could be improved.