Article type
Abstract
Background:
Long-term opioid therapy for chronic noncancer pain remains a contentious issue, and current guidelines provide conflicting recommendations.
Objective:
To provide recommendations for use of opioids in adults living with chronic noncancer pain
Methods:
A 20-member guideline panel, composed of patient partners, clinical experts, and methodologists, followed the GRADE approach to formulate recommendations for opioids and chronic noncancer pain. The panel developed a values and preferences statement and considered systematic reviews of randomized controlled trials to inform benefits and harms and reviews of observational studies to inform long-term and less frequent harms (eg, overdose). No panel member had important financial or intellectual conflicts of interest.
Results:
The panel recommended that non-opioid therapy be optimized before considering a trial of opioids (strong) and that a trial of opioids should be discussed with people living with chronic pain who do not achieve sufficient relief with non-opioid therapy unless they present with a current or past substance use disorder, other current psychiatric disorder, or a history of opioid overdose (strong). The panel recommended against a trial of opioids among people living with chronic pain who have a history of opioid overdose or an active alcohol use disorder (strong). The panel suggested against a trial of opioids for people living with chronic pain who present with a history of any substance use disorder or another mental health disorder (active or historical) (conditional). For patients undergoing a trial of opioids, the panel suggested avoiding doses higher than 80 mg morphine equivalent (conditional) and recommended avoiding doses higher than 150 mg (strong). The panel suggested rotation to another opioid if a currently prescribed opioid was unhelpful or associated with problematic side effects (conditional). The panel recommended that people living with chronic pain on long-term stable opioid therapy be approached very 6 to 12 months to consider a trial of tapering to the lowest effective dose (strong) and that patients who agreed to a trial of tapering and experiencing challenges be engaged in multidisciplinary support (conditional).
Conclusions and relevance:
Opioids may be helpful to a minority of people living with chronic pain who have not found success with alternate approaches.
Long-term opioid therapy for chronic noncancer pain remains a contentious issue, and current guidelines provide conflicting recommendations.
Objective:
To provide recommendations for use of opioids in adults living with chronic noncancer pain
Methods:
A 20-member guideline panel, composed of patient partners, clinical experts, and methodologists, followed the GRADE approach to formulate recommendations for opioids and chronic noncancer pain. The panel developed a values and preferences statement and considered systematic reviews of randomized controlled trials to inform benefits and harms and reviews of observational studies to inform long-term and less frequent harms (eg, overdose). No panel member had important financial or intellectual conflicts of interest.
Results:
The panel recommended that non-opioid therapy be optimized before considering a trial of opioids (strong) and that a trial of opioids should be discussed with people living with chronic pain who do not achieve sufficient relief with non-opioid therapy unless they present with a current or past substance use disorder, other current psychiatric disorder, or a history of opioid overdose (strong). The panel recommended against a trial of opioids among people living with chronic pain who have a history of opioid overdose or an active alcohol use disorder (strong). The panel suggested against a trial of opioids for people living with chronic pain who present with a history of any substance use disorder or another mental health disorder (active or historical) (conditional). For patients undergoing a trial of opioids, the panel suggested avoiding doses higher than 80 mg morphine equivalent (conditional) and recommended avoiding doses higher than 150 mg (strong). The panel suggested rotation to another opioid if a currently prescribed opioid was unhelpful or associated with problematic side effects (conditional). The panel recommended that people living with chronic pain on long-term stable opioid therapy be approached very 6 to 12 months to consider a trial of tapering to the lowest effective dose (strong) and that patients who agreed to a trial of tapering and experiencing challenges be engaged in multidisciplinary support (conditional).
Conclusions and relevance:
Opioids may be helpful to a minority of people living with chronic pain who have not found success with alternate approaches.