Opioids in Chronic Pain

CME credit available from Harvard Medical School through August 2022.

Published Materials

Pain is one of the most common reasons for visits to primary care providers every year. Yet, despite the prevalence, managing chronic pain remains a significant challenge. Current recommendations for addressing chronic pain focus on a multi-modal approach including non-drug and drug treatments. This module discusses the evidence-based management options, both drug and non-drug, for four common pain conditions: osteoarthritis, chronic low back pain, diabetic neuropathy, and fibromyalgia. Further it includes recommendations for managing patients who may require or already be taking opioids including monitoring opioid safety, prescribing naloxone, and identifying patients with problematic opioid use.

Overview for managing patients with chronic non-cancer pain

Managing pain requires establishing clear functional goals that center on activities which are important to each patient. In order to achieve these goals, a focus on non-opioid treatment options is recommended. For those patients who do require opioids, utilizing non-opioid options can reduce total opioid doses and help improve function.

Selecting evidence-based treatment options can be challenging, with some pain conditions having more options available to manage pain than others. Below is a summary of common options used to manage pain and a corresponding benefit to risk profile for each option. More details regarding the evidence behind these recommendations, please see the comprehensive evidence document.

Evidence-based recommendations for managing specific chronic pain conditions

For those patients who do require opioids, utilizing non-opioid options can reduce total opioid doses and help improve function.

Managing patients on chronic opioids

While opioids are not generally recommended for these four pain conditions, many patients already use opioids to manage pain. For these patients and others who may require a trial of an opioid medication, ensuring safety is critical. These steps are recommended for all patients taking opioids:1

  • Assess the risk and benefits of opioid use at every visit

  • Establish a written treatment agreement
  • Monitor opioid use
    • Check the prescription drug monitoring program
    • Use urine drug screens
  • Use caution with high daily opioid doses
Examples of opioids equivalent to 50 MMED

  • Prescribe naloxone to reduce overdose risk
    • Especially in patients prescribed >50 MMED, have renal or hepatic dysfunction, or are co-prescribed a benzodiazepine
  • Taper or discontinue

Algorithm for reducing opioid doses

When planning the taper:2,3

  • Go slow
  • Personalize the plan
  • Consult with experts as needed
  • Address mental health needs
  • Encourage patients

Resources for Providers
Information for Patients
State specific resources

 


Information current at time of publication, July 2019.

The content of this website is educational in nature and includes general recommendations only; specific clinical decisions should only be made by a treating clinician based on the individual patient’s clinical condition.


References
  1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. MMWR Recomm Rep. 2016;65(1):1-49.
  2. Dowell D, Haegerich T, Chou R. N Engl J Med. 2019; 380(24):2285-2287.
  3. FDA Drug Safety Communication April 9, 2019. fda.gov/drugs/drug-safety-and-availability/ fda-identifies-harm-reported-sudden-discontinuation-opioid-pain-medicines-and-requires-label-changes. Accessed 4 Aug 2019.
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